Medical Claim Review Nurse

Candidates can be located in an 1 of the 15 preferred work locations. PST, MTN, CNT, EST (after training work in time zone located)

6:00 - 6:00 (pick shift within these hours)



Job Description:

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.

Assists with Complex Claim review including DRG Validation, Itemized Bill Review, Appropriate Level of Care, Inpatient Readmission, and any opportunity identified by the Payment Integrity analytical team; 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 and support to clinical peers.

Identifies and refers members with special needs to the appropriate *** program per policy/protocol.



JOB QUALIFICATIONS

Graduate from an Accredited School of Nursing



REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES:

Minimum 3 years clinical nursing experience.

Minimum one year Utilization Review and/or Medical Claims Review.

Minimum two years of experience in Claims Auditing, Medical Necessity Review and Coding experience

Familiar with state/federal regulations



Job Summary

Utilizing clinical knowledge and experience, responsible for review of documentation to ensure medical necessity and appropriate level of care utilizing MCG/InterQual, state/federal guidelines, billing and coding regulations, and Client policies; validates the medical record and claim submitted support correct coding to ensure appropriate reimbursement to providers.



Required Years of Experience

Minimum 3 years clinical nursing experience.

Minimum one year Utilization Review and/or Medical Claims Review.

Minimum two years of experience in Claims Auditing, Medical Necessity Review and Coding experience

Familiar with state/federal regulations



REQUIRED LICENSE, CERTIFICATION, ASSOCIATION:

Active, unrestricted State Registered Nursing (RN) license in good standing



The initial project will focus on outpatient claims and specific CPT/HCPCS coding.

Behavioral health and general outpatient coding review and guidelines, reviewing documentation to support to services provided and ensuring all state/federal guidelines are met + Client coverage policies.