Clinical Review Nurse - Novitas

GuideWell Source

5h • Remote

About The Position

The Clinical Review Nurse is responsible for reviewing and making medical determinations as to the validity of health claims and levels of payment in meeting national and local policies as well as accepted medical standards of care. The incumbent applies clinical knowledge to assess the medical necessity, level of services and appropriateness of care which may include cases requiring prior authorization, complex pre-payment medical review or post-payment medical review.

Requirements

• High School diploma or GED
• 2 years' clinical experience
• Excellent written and oral communication skills
• Demonstrated experience with evaluating medical and health care delivery issues
• Strong computer skills to include Microsoft Office proficiency
• Valid unrestricted Registered Nurse (RN) license
• The Federal Government and the Centers for Medicare & Medicaid Services (CMS) may require applicants to have lived in the United States for a minimum of three (3) years out of the last five (5) years to be employed with the Company.

Nice To Haves

• Bachelor of Science in Nursing (BSN)
• Insurance industry experience
• Certified Coder

Responsibilities

• Review and analyze pre and post pay complex health care claims from a medical perspective, inclusive of prior authorization
• Perform clinical review work as assigned; may provide guidance to other team members and accurately interpret and apply broad CMS guidelines to specific and highly variable situations.
• Conduct review of claim data and medical records to make clinical decisions on the coverage, medical necessity, utilization and appropriateness of care per national and local policies, as well as accepted medical standards of care.
• Review provider practices and identify issues of concern, overpayment and need for corrective action as necessary; includes surfacing potential fraud and abuse or practice concerns.
• May develop recommendations for further corrective action based on medical review findings.
• May refer for review, or implement, corrective action related to medical review activities.
• May process claims and complete project work in the appropriate computer system(s).
• Identify providers needing education and individually educate providers who are subject to medical review processes
• Initiate or participate in provider teaching activities, creating written teaching material, providing one on one education or education to a group as a result of a medical review (e.g., probe, progressive corrective action, consent, etc.) or appeal.
• This may involve discussion with CMS leaders and leaders in the provider community.
• Participate in special projects as assigned.
• Performs other duties as the supervisor may, from time to time, deem necessary.

Benefits

• Medical, dental, vision, life and supplemental insurance plans effective the first day of the month following date of hire
• Short- and long-term disability benefits
• 401(k) plan with company match and immediate vesting
• Free telehealth benefits
• Free gym memberships
• Employee Incentive Plan
• Employee Assistance Program
• Rewards and Recognition Programs
• Paid Time Off and Paid Sick Leave

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED