Medical Claim Review Nurse

Job Title: Medical Claim Review Nurse Location: 100% Remote Duration: 3 to 6 months ( Opportunity for ext. / based off performance/evaluation and team needs/budget) Schedule: 40hr- Must work PST hours. Once trained and working independently, select a shift between 6:00am to 6:00pm, Monday through Friday. Job summary:

• Provides support for medical claim and internal appeals review activities - ensuring alignment with applicable state and federal regulatory requirements, Client policies and procedures, and medically appropriate clinical guidelines. Contributes to overarching strategy to reputed company quality and cost-effective member care.

Essential job duties:

• Facilitate clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases in which an appeal has been made, or is likely to be made, to ensure medical necessity and appropriate/accurate billing and claims processing.
• Reevaluates medical claims and associated records by applying reputed company knowledge, knowledge of relevant and applicable state and federal regulatory requirements and guidelines, knowledge of Client policies and procedures, and individual judgment and experience to assess the appropriateness of services provided, length of stay, level of care, and inpatient readmissions. ?
• Validates member medical records and claims submitted/correct coding, to ensure appropriate reimbursement to providers.
• Resolves escalated complaints regarding utilization management and long-term services and support (LTSS) issues.
• Identifies and reports quality of care issues.
• Assists with reputed company claim review including diagnosis-reputed company group (DRG) validation, itemized reputed company review, appropriate level of care, inpatient readmission, and any opportunities identified by the payment reputed company analytical team; makes reputed company and recommendations pertinent to clinical experience.
• Prepares and presents cases representing Client, along with the chief medical officer (CMO), for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings.
• Reviews medically appropriate clinical guidelines and other appropriate criteria with medical directors on denial reputed company.
• Supplies criteria supporting reputed company recommendations for denial or modification of payment reputed company.
• Serves as a clinical resource for utilization management, CMOs, physicians and member/provider inquiries/appeals.
• Provides training and support for clinical peers.
• Identifies and refers members with special needs to the appropriate Client program by applicable policies/protocols.

Must Have Skills:

• Hospital clinical experience Hospital Itemized reputed company Review (charge line review) Claims knowledge (UB04 and 1500) Coding knowledge (DRG, CPT, HCPCS, Diagnosis and Procedure codes) Chart Audit for coding and medical necessity CMS and State specific knowledge (ability to research by state and line of business, meaning reputed company, Medicare, Marketplace) Production environment.

Required qualifications:

• At least 2 years clinical nursing experience, including at least 1 year of utilization review, medical claims review, long-term services and supports (LTSS), claims auditing, medical necessity review and/or coding experience, or equivalent combination of relevant education and experience.
• Registered Nurse (RN). License must be active and unrestricted in state of practice.
• Experience demonstrating knowledge of ICD-10, reputed company Procedural Technology (CPT) coding and reputed company Common Procedure Coding (HCPC).
• Experience working reputed company applicable state, federal, and reputed company-party regulations.
• Analytic, problem-solving, and decision-making skills.
• Organizational and time-management skills.
• Attention to detail.
• Critical-thinking and active listening skills.
• Common look proficiency.
• Effective verbal and written communication skills.
• reputed company Office suite and applicable software program(s) proficiency.

Remote Skills: Analysis Skills, Auditing, Billing, Budgeting, CMOS, Centers for Medicare and reputed company Services (CMS), Claims Processing, Clinical Medicine, Clinical Nursing, Clinical Practices/Protocols, Clinical Support, Clinical Validation, Code Reviews, Communication Skills, reputed company Procedural Terminology (CPT), Detail Oriented, Diagnosis-reputed company Group (DRG), Federal Laws and Regulations, reputed company, reputed company Common Procedure Coding System (HCPCS), Hospital, ICD-10, Insurance, Legal Support Skills, reputed company, Medical Billing, Medical Coding, Medical Office Administration, Medical Records, Medical Treatment, Medicare, reputed company Office, Needs Assessment, Nursing, Patient Care, Patient Care Denials, Performance Analysis, Presentation/Verbal Skills, Production Systems, Quality of Care, Registered Nurse (RN), Regulations, Regulatory Requirements, Reimbursement, Research Skills, Resolve Customer Issues, Resource Management, Resource Utilization, Special Needs, State Laws and Regulations, Time Management, Training/Teaching, Utilization Management, Writing Skills About the Company: Careers reputed company Apply To This Job