1+ months

Medical Review Nurse Team Lead (Commercial - All Clients)

Regular Full Time


The Medical Review Nurse Team Lead serves as first level of resource and escalation for ateam of Medical Review Nurses conducting clinical audits on healthcareclaims.  Provides support to managementin planning, staffing, workflow, continuous improvement initiatives,performance feedback, training and other functions.  This position requires an experienced healthcaremedical claims review nurse with leadership skills who is able to adjustpriorities dynamically in a fast-paced work environment while maintaining highquality standards. 

Essential JobFunctions:

  • Supports inventory management and makes staff assignment recommendations to meet business needs and audit timelines
  • Assists in the development, maintenance, and training of Medical Review Guidelines
  • May train new auditors 1:1 or in classroom setting
  •       Serves as first level resource for the clinical auditors in terms of claim specific questions, industry standards and escalation of  issues
  •         Ensures auditors are equipped with tools and resources required to perform audits
  •         Actively provides recommendations for audit that will increase productivity, maintain quality, cost containment, or other continuous improvement initiatives
  •          Work with assigned team to improve quality and documentation and minimize appeals
  •          Work with team to maximize productivity to achieve targeted goals
  •          Serves as a critical point of contact between team members and management
  •          Provides constructive support and feedback to auditors regarding their audit productivity and quality as needed, utilizing best practices
  •          Assists in disseminating information to the team in a timely manner and ensuring understanding and application as applicable
  •          Keeps management informed of important issues and trends prepares reports and summaries for management as needed
  •          Interacts with management to identify training needs and best practices
  •         Works collaboratively with the audit team to identify areas of opportunities for improvement and/or deficiencies
  •         Reports to management as required on deficiencies, performance, employee relations, other issues, including scope of problem or opportunity and recommended resolutions
  •          May participate in interview and screening process for new auditors
  • May perform clinical review for audits and/or quality assurance based upon business volume or special projects.
  •         Creates a team environment that fosters open communication and sharing of information
  • Receives feedback and adjusts work priority as necessary
  • Maintains current knowledge of changes in technology, practice and regulatory issues that may affect our business and clients
  • Assists with quality assurance functions and contributes to the development of medical review guidelines and training
  • Identifies and recommends opportunities for cost savings and improving outcomes that can have a direct impact to the company's bottom line
  • Leads by example and conducts work in accordance with company policies, government regulations and law.
  • Completes all assigned training as may be required by the company and/or clients
  • Performs other duties as assigned

Required Skills and Knowledge:
  • Self starter /works with minimum supervision
  • Demonstrated strong verbal and written communication skills; ability to write clearly and informatively, and effectively convey information in a professional and appropriate manner; communicate effectively at all levels internal and external to the department and organization.
  • Excellent editing and proofreading skills
  • Strong analytical skills; synthesizes complex or diverse information; collects and researches data; uses experience to compliment data.
  • Ability to effectively resolve complex issues.
  • Demonstrated ability to create efficiencies in workflows and procedures.
  • Demonstrated ability to be proactive; identifies and resolves problems in a timely manner; develops alternative solutions.
  • Demonstrated ability to collaborate effectively in a variety of settings and topics.
  • Ability to independently organization, prioritize and plan work activities for self and others; develops realistic action plans with the ability to multi-task effectively.
  • Understand processes, procedures and work flow, identify areas of weakness
  • Independent, Out-of-the-box thinker; Performs successfully against work given in the form of objectives and projects
  • Strong general technical skills, including, but not limited to Desktop and MS Office applications and case management system/tools to review and document findings.
  • Flexibility to apply skills to various tasks and adaptable to changing business needs and shifting priorities.


Education and Experience:


  • Current active unrestricted RN license in good standing required
  • Not currently sanctioned or excluded from the Medicare program by OIG
  • Medical coding certification preferred 
  • Minimum of 3 years diversified nursing experience providing direct care in an inpatient or outpatient setting.
  • 5+ years progressive professional relevant experience in medical record utilization review function at a senior level.
  • 5+ years experience in health care claims that demonstrates expertise in ICD-9/ICD-10 coding, HCPS/CPT coding, DRG and medical billing experience for an Insurance Company or hospital required.
  • Prior lead or supervisory experience desired


Other Requirements:

-Must submit to and pass background check. 
-Must be able to pass a criminal background check; must not have any felony convictions or specific misdemeanors.
-Must submit to and pass drug screen.

Performant is a government contractor. Certain client assignments for this position requires submission to and successful outcome of additional background and/or clearances throughout employment with the Company.

Job Profile is subject to change at any time.

Performant Financial Corporation is an Equal Opportunity Employer. Performant Financial Corporation is committed to creating a diverse environment and is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, age, religion, gender, gender identity, sexual orientation, pregnancy, age, physical or mental disability, genetic characteristics, medical condition, marital status, citizenship status, military service status, political belief status, or any other consideration made unlawful by law.

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Posted: 2021-07-02 Expires: 2021-10-16
Analytics, audit, and recovery services for healthcare, government and student loans.

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Medical Review Nurse Team Lead (Commercial - All Clients)

Performant Financial

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