Medical Review Nurse

GRP SCAN Group•Long Beach, CA

1d•$39 - $56•Remote

About The Position

SCAN Group is a not-for-profit organization dedicated to tackling the most pressing issues facing older adults in the United States. SCAN Group is the sole corporate member of SCAN Health Plan, one of the nation’s leading not-for-profit Medicare Advantage plans, serving more than 300,000 members in California, Arizona, Nevada, Texas, New Mexico & Washington. SCAN has been a mission-driven organization dedicated to keeping seniors healthy and independent for more than 45 years and is known throughout the healthcare industry and nationally as a leading expert in senior healthcare. SCAN employees are a group of talented, passionate professionals who are committed to supporting older adults on their aging journey, while also innovating healthcare for seniors everywhere. Employees are provided in-depth training and access to state-of-the-art tools necessary to do their jobs, as well as development and growth opportunities. SCAN takes great pride in recognizing our team members as experts in their fields and rewarding them for their efforts. If you are interested in becoming part of an organization that is innovating senior healthcare visit www.thescangroup.org , www.scanhealthplan.com , or follow us on LinkedIn, Facebook, and Twitter. The Job 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.

Requirements

Associate's Degree or equivalent experience required
Current and active California RN License in good standing required
3-5 years of related experience in clinical decision making relative to Medicare patients.
Certifications deemed to be reasonable to function at this level.
Performs work under minimal supervision.
Handles complex issues and problems and refers only the most complex issues to higher-level staff.
Possesses comprehensive knowledge of subject matter.
Technical expertise
Strong technical skills for functional area
Problem Solving
Strong problem-solving skills
Communication
Good communication and interpersonal skills
Ability to work as part of a team.
Oral and written communication skills.
Problem-solving skills.
Attentiveness.
Interpersonal skills

Nice To Haves

Bachelor's Degree or equivalent experience preferred
Certified Professional Coder preferred.

Responsibilities

Review and analyze pre and post payment of complex health care claims from a medical perspective.
Perform audits/reviews of medical claims per established criteria, identify need for medical record review, necessary documentation to support decision making process regarding appropriateness of claim, billed charges, benefit coverages
Provide guidance to other staff members and accurately interpret and apply broad Centers for Medicare and Medicaid Services (CMS) guidelines to specific and highly variable situations
Conduct review of claims 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) as assigned and as necessary and appropriate
Process workload and complete project work in the appropriate computer system(s).
Contribute to team effort by accomplishing related results as needed.
Route identified clinical and/or risk issues to appropriate personnel eg, Medical Director, Quality of Care (QOC) Nurse, Medical Management Specialist, Member Services, etc
Review/prepare potential claims denials in conjunction with Medical Director
Collaborate with Medical Director pursuant to adjudication of claims and post service appeals
Participate in special projects/workgroups/committees (eg, interdisciplinary workgroups, report analysis, independent review entity (IRE) etc. as assigned and as necessary and appropriate.
Actively support the achievement of SCAN’s Vision and Goals.
Other duties as assigned.

Benefits

Base salary range: $38.61 to $55.86 per hour
Remote position
An annual employee bonus program
Robust Wellness Program
Generous paid-time-off (PTO)
Eleven paid holidays per year, plus 1 floating holiday, plus 1 birthday holiday
Excellent 401(k) Retirement Saving Plan with employer match and contribution
Robust employee recognition program
Tuition reimbursement
An opportunity to become part of a team that makes a difference to our members and our community every day!