Job Description

Position Title: Medical Claims Review Nurse
Type: Fully Remote

Daily Responsibilities:

• Reviewing medical patient records against standard medical criteria.

Minimum Qualifications:

• Three years of clinical appeals experience.
• One year of utilization review experience.
• Candidates with DRG experience on their resume will be prioritized for interviews.

Job Summary:

• Perform clinical/medical reviews of retrospective medical claim reviews, medical claims, and previously denied cases.
• Ensure medical necessity and appropriate/accurate billing and claims processing.
• Identify and report quality of care issues.
• Refer members with special needs to appropriate healthcare organization programs.
• Assist with complex claim review requiring decision-making based on clinical experience.
• Document clinical review summaries, bill audit findings, and audit details in the database.
• Provide supporting documentation for denial and modification of payment decisions.
• Re-evaluate medical claims independently by applying advanced clinical knowledge and relevant regulatory requirements.
• Review clinical guidelines with Medical Directors on denial decisions.
• Serve as a clinical resource for various stakeholders.
• Provide training, leadership, and mentoring.
• Resolve escalated complaints regarding utilization management and long-term services and supports.
• Prepare and present cases for various hearings as required.

Job Function:

• Administer claims payments, maintain claim records, and provide counsel to claimants.
• Monitor and control backlog and workflow of claims.
• Ensure timely settlement of claims in accordance with cost control standards.

Required Education:

• BSN Preferred.

Required Experience:

• Minimum three years of clinical appeals review experience.
• Minimum one year of utilization review.

Required License, Certification, Association:

• Active, unrestricted State Registered Nursing (RN) license in good standing.
• LPN/LVN Considered based on experience

• $90,000 and up plus full benefit package

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