Medical Management - Medical Review Examiner Nurse 135-1009

Community Care • Tulsa, OK

1d

About The Position

The Medical Review Examiner Nurse is responsible for auditing provider and facility claims. Identifying issues related to and/or participates in various projects aimed at identifying areas of non-compliance and/or potential fraud, waste and abuse, as it relates to provider billing practices.

Requirements

• Extensive knowledge of ICD-9, ICD-10, HCPS, CPT-4 codes.
• Able to work independently and meet stringent deadlines.
• Successful completion of Health Care Sanctions background check.
• Proficiency in claims processing software and Microsoft applications.
• Possess strong oral and written communication skills.
• Current, active, unrestrictive license to practice as Registered Nurse (RN) or Licensed Practical Nurse (LPN) in the State of Oklahoma.
• Five years of work experience in hospital, clinic or health plan clinical operations (for example utilization review, quality improvement, clinical claims review).

Nice To Haves

• Bachelor’s Degree preferred.
• Experience or familiarity with state and federal regulations governing healthcare preferred.

Responsibilities

• Review claims by requesting medical records and other documents to evaluate for clinical appropriateness, coding compliance and validity of charges.
• Document ineligible charges and provide communications internally for claims processing and externally to providers.
• Provide review of complex claims for further research meeting the MRE “pend” criteria.
• Collaborate with Medical Director and/or other departments (and resources) to make claim determinations.
• Maintain tracking database including self-audit for quality control.
• Compile and analyze data and prepare routine reports as assigned.
• Identify trends and formulate recommendations based on findings.
• Suggest opportunities for special study.
• Serve as an internal resource to provider services, contracting, claims, medical management, configuration, and appeals & grievances.
• Provide guidance as it relates to clinical appropriateness of services.
• Participate in provider education upon request.
• Maintain files of MRE records.
• Participate in special projects and audits as assigned.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree