Medical Management - Medical Review Examiner Nurse 135-1009
CommunityCare•Tulsa, OK
About The Position
The Medical Review Examiner Nurse audits provider and facility claims and identifies issues related to provider billing practices, including potential non-compliance, fraud, waste, and abuse. The role reviews claims and supporting medical records to assess clinical appropriateness, coding compliance, and the validity of charges. It also researches complex claims, collaborates with the Medical Director and other departments on claim determinations, maintains quality-control and tracking records, analyzes data, and supports internal teams and provider education.
Requirements
- Current, active, unrestricted license to practice as a Registered Nurse (RN) or Licensed Practical Nurse (LPN) in Oklahoma.
- Associate degree required.
- Five years of work experience in hospital, clinic, or health plan clinical operations, such as utilization review, quality improvement, or clinical claims review.
- Extensive knowledge of ICD-9, ICD-10, HCPS, and CPT-4 codes.
- Ability to work independently and meet stringent deadlines.
- Successful completion of a Health Care Sanctions background check.
- Proficiency in claims processing software and Microsoft applications.
- Strong oral and written communication skills.
Nice To Haves
- Bachelor’s degree.
- Experience or familiarity with state and federal regulations governing healthcare.
Responsibilities
- Request and review medical records and other documents to evaluate claims for clinical appropriateness, coding compliance, and validity of charges.
- Document ineligible charges and communicate findings internally for claims processing and externally to providers.
- Review complex claims requiring further research under the MRE “pend” criteria.
- Collaborate with the Medical Director and other departments or resources to make claim determinations.
- Maintain a tracking database, including self-audits for quality control.
- Compile and analyze data, prepare routine reports, identify trends, formulate recommendations, and suggest opportunities for special studies.
- Serve as an internal resource to provider services, contracting, claims, medical management, configuration, and appeals and grievances.
- Provide guidance regarding the clinical appropriateness of services and participate in provider education upon request.
- Maintain files of MRE records.
- Participate in special projects and audits as assigned.
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What This Job Offers
Job Type
Full-time
Education Level
Associate degree
