Nurse Reviewer RN

Federal Hearings And Appeals • Wilkes-Barre, PA

6d • Remote

About The Position

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.

Requirements

• Must possess a current, unrestricted State license as a Registered Nurse (RN), as required by contract(s)
• 1+ years clinical experience required
• Must be proficient with PC and related software programs
• Must be a team player

Nice To Haves

• Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) certification through the American Academy of Professional Coders (AAPC) or AHIMA preferred
• coding, utilization, and/or medical chart review preferred
• Professional Coding Certification preferred
• Detailed knowledge of Medicare regulations and guidelines, polices, and payor reimbursements preferred
• 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
• Excellent organizational skills

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

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level