Medical Claim Review Nurse

Job Description:
Position is fully remote Candidates can sit anywhere in the US and schedule will be M-F 9AM-5PM local time.
The training schedule will be M-F 9AM-5PM EST.
Daily responsibilities will include the following:
Candidates will be reviewing medical patient records aProductst standard medical criteria

JOB SUMMARY:
Performs clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases, in which an appeal has been submitted, to ensure medical necessity and appropriate/accurate billing and claims processing.
Identifies and reports quality of care issues. Identifies and refers members with special needs to the appropriate *** program per policy/protocol.
Assists with Complex Claim review; requires decision making pertinent to clinical experience. Documents clinical review summaries, bill audit findings and audit details in the database Provides supporting documentation for denial and modification of payment decisions Independently re-evaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of all relevant and applicable Federal and State regulatory requirements and guidelines, knowledge of Client policies and procedures, and individual judgment and experience to assess the appropriateness of service provided, length of stay and level of care Reviews medically appropriate clinical guidelines and other appropriate criteria with Medical Directors on denial decisions.
Supplies criteria supporting all recommendations for denial or modification of payment decisions.
Serves as a clinical resource for Utilization Management, Chief Medical Officers, Physicians, and Member/Provider Inquiries/Appeals.
Provides training, leadership and mentoring for less experienced clinical peers and LVN, RN and administrative support staff.
Resolves escalated complaints regarding Utilization Management and Long Term Services & Supports issues.
Identifies and reports quality of care issues.
Prepares and presents cases in conjunction with the Chief Medical Officers Medical Directors for Administrative Law Judge pre-hearings, State Insurance Commission, and Meet and Confers.
Represents Client and presents cases effectively to Judicial Fair Hearing Officer during Fair Hearings as may be required.
Candidates MUST have 3 years of clinical appeals experience along with 1 year of utilization review experience.
Candidates with DRG experience on the resume will be prioritized for interviews. Candidates for these positions must have previous experience/skills/qualification with itemized bill review.

JOB FUNCTION:
Responsible for administering claims payments, maintaining claim records, and providing counsel to claimants regarding coverage amount and benefit interpretation. Monitors and controls backlog and workflow of claims. Ensures that claims are settled in a timely fashion and in accordance with cost control standards

Minimum three years clinical appeals review experience.
Minimum one year Utilization Review
Active, unrestricted State Registered Nursing (RN) license in good standing.
For these 2 positions we are looking for someone with itemized bill review experience specifically.

PREFERRED LICENSE, CERTIFICATION, ASSOCIATION: Certified Clinical Coder, Certified Medical Audit Specialists, Certified Case Manager , Certified Professional Healthcare Management, Certified Professional in Healthcare Quality or other healthcare certification