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Job Requirements of Medical Claim Review Nurse (RN):
-
Employment Type:
Contractor
-
Location:
Dallas, TX (Onsite)
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Medical Claim Review Nurse (RN)
Careers Integrated Resources Inc
Dallas, TX (Onsite)
Contractor
Job Title: Medical Claim Review Nurse (RN)
Location: 100% Remote
Duration: 6 months+ (Possibility of extension)
Work Hours: Monday-Friday 9 AM to 5 PM local time (The training schedule will be M-F 9AM-5PM EST)
Job Description:
Job Summary:
Job Function:
Required Education:
Required Experience:
Required License, Certification, Association:
Location: 100% Remote
Duration: 6 months+ (Possibility of extension)
Work Hours: Monday-Friday 9 AM to 5 PM local time (The training schedule will be M-F 9AM-5PM EST)
Job Description:
- This position is fully remote.
- Daily responsibilities will include the following: Reviewing medical patient records against standard medical criteria.
- Candidates must live in one of the preferred 15 states (Arizona, Florida, Georgia, Idaho, Iowa, Kentucky, Michigan, Nebraska, New Mexico, New York (outside greater-NYC), Ohio, Texas, Utah, Washington (outside greater-Seattle), Wisconsin); will be able to work in their own time zone
- 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.
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 Client Healthcare 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.
- 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.
- 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.
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.
Required Education:
- Highschool Diploma or GED
Required Experience:
- Minimum three years clinical appeals review experience.
- Minimum one year Utilization Review
Required License, Certification, Association:
- Active, unrestricted State Registered Nursing (RN) license in good standing.
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