Clinical Review Nurse I- Medicare Part A
About The Position
The Clinical Review Nurse I - Medicare Part A reviews documentation and makes clinical determinations for payment of claims submitted to Medicare. The role applies clinical knowledge to determine whether billed services and items are reasonable and necessary, supported by national and local policies, consistent with accepted billing and coding practices, and meet standards of medical care. The nurse adapts to a wide variety of medical review topics in Part A appeals and communicates clearly with clinicians and support personnel. The role also reviews and determines whether claims meet the benefits carried by the member. This position is with Wellpoint Federal, a subsidiary of Elevance Health that supports federal programs through claims administration, data, and care delivery. The role investigates and reviews member and provider grievances and appeals, assesses claims using medical policies and other materials, prepares written correspondence, and ensures matters are resolved within regulatory timeframes. The role is described as virtually full-time, with required in-person training sessions. Candidates generally must live within reasonable commuting distance of a posting location, unless an accommodation is granted as required by law. The stated schedule is Monday through Friday, 8 a.m. to 5 p.m. EST/CST.
Requirements
- Associate degree in nursing and at least 1 year of clinical experience, or an equivalent combination of education and experience.
- Current unrestricted RN license.
- For the Wellpoint Federal division, foreign national applicants must have lived in the United States for at least three of the past five years, per CMS TDL 190275.
Nice To Haves
- Bachelor of Science in nursing.
- Part A Home Health and Hospice claim review experience.
- Strong computer skills.
- Experience with MAS or another CMS mainframe system.
- Ability to comprehend medical policies and apply criteria effectively to make informed medical review decisions, and communicate those decisions clearly and concisely.
- Part A Medicare experience.
- Prior experience with Medicare claims review.
- Experience in surgical services and ICU.
Responsibilities
- Review documentation and make clinical determinations for payment of Medicare claims.
- Assess whether billed services and items are reasonable and necessary using medical policies and other materials.
- Determine whether services and items are supported by applicable national and local policies, accepted billing and coding practices, and standards of medical care.
- Adapt to a wide variety of medical review topics in Part A appeals.
- Communicate clinical determinations clearly with medical doctors, nurses, and support personnel.
- Determine whether claims meet the benefits carried by the member.
- Conduct investigations and reviews of member and provider grievances and appeals.
- Generate appropriate written correspondence to providers, members, and regulatory entities.
- Ensure appeals and grievances are resolved timely to meet regulatory timeframes.
Benefits
- Comprehensive benefits package, subject to eligibility requirements.
- Incentive and recognition programs.
- Equity stock purchase.
- 401(k) contribution.
- Merit increases.
- Paid holidays.
- Paid Time Off.
- Incentive bonus programs, unless covered by a collective bargaining agreement.
- Medical, dental, and vision benefits.
- Short- and long-term disability benefits.
- 401(k) match.
- Stock purchase plan.
- Life insurance.
- Wellness programs.
- Financial education resources.
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
Associate degree
