Clinical Claim Review RN
About The Position
The Clinical Claim Review Nurse performs claim reviews to verify correct coding and correct charges. The clinical reviewer is responsible for documenting, researching state and federal guidelines and following internal procedures to determine the viability of the claim for further review in a production environment. Employees in this position receive limited supervision within a broad framework of policies and procedures and possess a comprehensive understanding of the claim review process including clinical claim review, medical record review, and a broad knowledge of applicable processes, procedures and billing guidelines. You’ll enjoy the flexibility to telecommute from anywhere within the U.S. as you take on some tough challenges.
Requirements
- Associates degree
- Active and unrestricted RN license in the state of residence
- 2+ years of clinical experience within an acute care setting
- 1+ years of experience in one of the following areas Utilization Management, pre-authorization, claim review, appeals review, or medical record review.
- Intermediate level of computer skills including proficiency in Microsoft Office, Word, Excel, Outlook, and SharePoint
Nice To Haves
- Auditing and coding certifications (CPC, COC, CIC, CPB, CPMA) or ability to obtain within 1 year of employment
- CPT & HCPCS Coding experience
- Experience working with medical terminology and coding
- Proven ability to work independently
- Experience working with plan benefit language and CMS (Medicaid and Medicare)
- Strong written and verbal communication skills
- Strong organizational and critical thinking skills
Responsibilities
- Perform clinical review of professional or facility claims vs. medical records to determine if the claim is supported or unsupported.
- Maintain standards for productivity and accuracy. Standards are defined by the department
- Complete analysis of billing and departmental guidelines
- Provide clear and concise clinical logic to the clients and providers when necessary
- Participation as needed in the achievement and completion of department goals
- Complete focused review of medical records to evaluate clinical course of care as applicable
- Assists with resolution of claims as needed to support negotiations and appeals process
- Ensure adherence to state and federal compliance policies, reimbursement policies, and contract compliance
- Maintains appropriate documentation on all claims according to departmental guidelines and procedures
- Understand and maintain HIPAA confidentiality and privacy standards when completing assigned work
Benefits
- Competitive base pay
- Full and comprehensive benefit program
- Performance rewards
- Paid Time Off which you start to accrue with your first pay period
- 8 Paid Holidays
- Medical Plan options
- Health Spending Account or a Health Saving account
- Dental, Vision, Life& AD&D Insurance
- Short-term disability and Long-Term Disability coverage
- 401(k) Savings Plan
- Employee Stock Purchase Plan
- Education Reimbursement
- Employee Discounts
- Employee Assistance Program
- Employee Referral Bonus Program
- Voluntary Benefits (pet insurance, legal insurance, LTC Insurance, etc.)
- Incentive and recognition programs
- Equity stock purchase
- 401k contribution
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
