Medical Review Nurse
About The Position
The Medical Review Nurse (Senior Clinical Reviewer) works to summarize and correlate concise, accurate information on medical reviews to determine eligibility of medical bills per the program guidelines. In this role, 70% of the time is spent performing pre-service and post-service medical reviews and/or reviews for high dollar, complex medical cases and collaborating with other departments to optimize cost savings. This position will be expected to make independent decisions regarding timing and omission of medical reviews in deference to other department processes based on the dollar amount of the bill and the Ministry’s cost strategy.
Requirements
- Understanding of medical bill processing and provider bill negotiation
- Understand diversity of systems and work flows as they relate to the type of review or assignment
- Able to multitask in multiple operating systems
- Able to work for extended periods of time on the computer
- Proficiency at interpreting medical records and writing detailed reports and conclusions
- Strategic understanding of negotiations, third party processes, bill validation, and care management to determine when to utilize/defer to these processes for active review cases
- Ability to be objective and impartial and conclude a case
- Ability to communicate effectively with both internal and external customers
- Practice good interpersonal skills and work as a member of a team
- Possess the ability to adapt to changing processes
- Working knowledge and application of program guidelines
- Understanding of systems and work flows as they relate to the type of review or assignment
- Ability to utilize the internet including e-mail and search engines
- Word processing skills of at least 25 wpm
- Basic knowledge in Microsoft Office (Excel, Word, Outlook) and ability to use a database system
- Knowledge of document imaging system
- Current Unrestricted LPN/LVN license with 5+ years’ experience in a healthcare payer industry OR RN license with sound knowledge of anatomy and physiology and disease processes required
- 1-3 years’ experience in medical reviews required
Nice To Haves
- 2-3 years of clinical experience strongly preferred
- Experience with Utilization Review or Case Management preferred
Responsibilities
- Organize and review medical records, lab results, radiology, and pathology reports for conditions ineligible for sharing (CIF’s)
- Determine eligibility of members’ medical bills and/or upcoming procedures/treatments according to the program guidelines
- Collaborate with other departments to maximize cost savings for individual cases and optimal outcomes for the members
- Appropriately apply the program guidelines to the individual cases reviewed
- Work autonomously to prioritize and manage workload
- Document effectively in appropriate systems
- Comply with all organizational HIPAA requirements
- Contribute to the exercise and expression of the Ministry’s Christian beliefs
- All other duties as assigned
Benefits
- 100% paid Medical for employees/99% for family
- Generous employer Health Savings Account (HSA) contributions
- Employer-paid Life Insurance (3x salary) and Long-term Disability Insurance
- 6 weeks of paid parental leave (for both mom and dad)
- Dental - two plans to choose from
- Vision
- Short-term Disability
- Accident, Critical Illness, Hospital Indemnity
- 401(k) – up to 4% match on ROTH or Traditional contributions
- Generous paid-time off and 11 paid holidays
- Wellness plan including Financial, Occupational, Mental/Spiritual, and Physical health incentives up to $50/mo
- Employee Assistance Program including no cost, in-person mental health visits and employee discounts
- Monetary Anniversary Awards Program
- Monetary Birthday Awards
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
Number of Employees
501-1,000 employees
