Medical Review Nurse

SCAN Health Plan • Long Beach, CA

1d • Remote

About The Position

Provide clinical review of medical claims and post-service appeals. Facilitate appropriate investigation of issues and management of medical services and benefits administration while maintaining SCAN timeframe standards. This role reviews complex health care claims from a medical perspective, applies CMS guidelines and relevant coverage and care policies, and collaborates with medical and operational personnel to support claims decisions. The position is remote.

Requirements

• Associate degree or equivalent experience.
• Current and active California RN license in good standing.
• Three to five years of related experience in clinical decision-making involving Medicare patients.
• Certifications considered reasonable for functioning at this level.
• Ability to perform work under minimal supervision.
• Ability to handle complex issues and problems and refer only the most complex issues to higher-level staff.
• Comprehensive knowledge of the subject matter.
• Technical expertise and strong technical skills for the functional area.
• Strong problem-solving skills.
• Good communication and interpersonal skills, including oral and written communication.
• Ability to work as part of a team.
• Attentiveness.

Nice To Haves

• Bachelor’s degree or equivalent experience.
• Certified Professional Coder certification.

Responsibilities

• Review and analyze complex health care claims before and after payment from a medical perspective.
• Perform audits and reviews of medical claims using established criteria; identify when medical record review is needed and what documentation is necessary to support decisions about claim appropriateness, billed charges, and benefit coverage.
• Guide other staff members and accurately interpret and apply CMS guidelines to specific and highly variable situations.
• Review claims data and medical records to make clinical decisions about coverage, medical necessity, utilization, and appropriateness of care according to national and local policies and accepted medical standards of care, as assigned and appropriate.
• Process workload and complete project work in the appropriate computer systems.
• Contribute to team efforts by accomplishing related results as needed.
• Route identified clinical or risk issues to appropriate personnel, such as the Medical Director, Quality of Care Nurse, Medical Management Specialist, or Member Services.
• Review and prepare potential claims denials in conjunction with the Medical Director.
• Collaborate with the Medical Director on adjudication of claims and post-service appeals.
• Participate in special projects, workgroups, and committees as assigned and appropriate, including interdisciplinary workgroups, report analysis, and independent review entity activities.
• Support the achievement of SCAN’s vision and goals.
• Perform other duties as assigned.

Benefits

• Annual employee bonus program.
• Robust wellness program.
• Generous paid time off.
• Eleven paid holidays per year, plus one floating holiday and one birthday holiday.
• 401(k) retirement savings plan with employer match and contribution.
• Employee recognition program.
• Tuition reimbursement.

What This Job Offers

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