Nurse Reviewer RN
About The Position
This role involves timely review and determination of medical claims, including prior authorization, appeals, and other claim types. The Nurse Reviewer will analyze medical records, interpret policies like Local Coverage Determination (LCD) and National Coverage Determination (NCD), and apply relevant regulatory citations and health plan policies. A key responsibility is to formulate narrative decisions citing regulatory back-up documentation and adjudicate claims based on regulations and medical records. The position also requires attending training sessions, completing surveys, and maintaining a high quality score.
Requirements
- Must possess a current, unrestricted State license as a Registered Nurse (RN), as required by contract(s)
- 1+ years clinical experience required
- Knowledge of CPT, HCPCS, ICD-10 codes and coding guidelines
- Ability to identify Medicare billing and payment irregularities
- Must be able to support review findings by utilizing exceptional analytical, written and oral communication skills
- Ethical, self-motivated and results oriented team player
- Strong analytical, verbal and written communication skills
- Outstanding people skills and ability to effectively review findings /results with management
- Must be proficient with PC and related software programs
- Excellent organizational skills
- Must be a team player
- Must be able to remain in the stationary position 95% of the time
- Constantly operate a computer and other office equipment such as telephone
- Regular & predictable attendance is essential for this position
Nice To Haves
- Coding, utilization, and/or medical chart review preferred
- Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) certification through the American Academy of Professional Coders (AAPC) or AHIMA preferred
- Professional Coding Certification preferred
- Detailed knowledge of Medicare regulations and guidelines, polices, and payor reimbursements preferred
Responsibilities
- Provide timely review and determination of medical claims, including prior authorization, appeals, and/or any other type of medical claims
- Analyze medical records related to the case file
- Review and interpret Local Coverage Determination (LCD), National Coverage Determination (NCD) policies, and other federal regulations
- Apply appropriate regulatory citations, including health plan policies, NCD/LCDs, and/or other regulations to each claim as it relates to the item or issue
- Formulate a narrative decision citing relevant regulatory back-up documentation contained within the medical record
- Adjudicate claim based on the regulations and documentation contained within the medical record
- Attend FHAS and/or client Lunch & Learn sessions and/or general training sessions on site as needed
- Complete IRR surveys in a timely fashion as required by the prime contractor
- Maintain a 97% or higher quality score
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
