Clinical Appeal & Claim Review Nurse I

Medical Mutual•Cleveland, OH

5d•Remote

About The Position

Working under general supervision, builds and applies knowledge to evaluate clinical information using evidence-based guidelines, company policies and individual patient considerations to ensure the provisions of safe, timely and appropriate healthcare services. Promotes effective use of resources and provides assistance to members in managing their health care across the continuum of care.

Requirements

Graduate of a registered nursing program approved by the Ohio State Nursing Board.
1 to 3 years of experience as a Registered Nurse in acute care, critical care, emergency medical or medical surgical or a combination of clinical and utilization/case management experience in the health insurance industry.
Registered Nurse with current State of Ohio unrestricted license.
Clinical knowledge and understanding of health care delivery processes.
Knowledge of medical terminology and managed care processes.
Knowledge of clinical claim management including ICD 10, CPT, HCPC, and revenue codes.
Knowledge of health care regulations.
Computer navigation and keyboarding proficiency; Intermediate Microsoft Office skills.

Nice To Haves

Bachelor’s degree preferred.
Experience in clinical documentation improvement, medical coding or medical documentation investigation preferred.
Certified Medical Coder (CPC, CCS, or equivalent) credential preferred.

Responsibilities

Evaluates basic to moderately complex medical claims and/or appeal cases and associated records by applying clinical, regulatory, and policy and procedures knowledge and experience to assess the appropriateness of service provided, length of stay and level of care.
Extrapolates and summarizes medical information for physician review or other external review.
Generates appropriate written status of review to providers, members, and regulatory entities advising of status.
Acts as a resource to the provider community, explaining processes for accessing health plan to perform clinical review, identifying appropriate community resources, or otherwise interacting with health plan programs and services.
Collaborates with providers, members and various internal departments to ensure that members are getting appropriate care at the most appropriate time.
Keeps up to date on utilization management regulations, policies and practices, including applicable coding.
Collaborates with more senior level staff on escalated claims and appeals records.
Performs other duties as assigned.

Benefits

A Great Place to Work
Laptop, monitors, keyboard, mouse and headset provided.
Access to on-site fitness centers or gym membership reimbursement.
On-site cafeteria.
Discounts at many places.
Opportunity to earn cash rewards for shopping with customers.
Business casual attire, including jeans.
Employee bonus program.
401(k) with company match up to 4% and an additional company contribution.
Health Savings Account with a company matching contribution.
Excellent medical, dental, vision, life and disability insurance.
Access to an Employee Assistance Program.
Company holidays and up to 16 PTO days during the first year of employment with options to carry over unused PTO time.
Parental leave for eligible employees who become parents through maternity, paternity or adoption.
Career development programs and classes.
Mentoring and coaching.
Tuition reimbursement up to $5,250 per year.
Diverse, inclusive and welcoming culture with Business Resource Groups.