Senior Nurse Reviewer- Remote

Gainwell Technologies LLC•Any city, OH

1d•$78,000 - $99,200•Remote

About The Position

We are seeking a talented individual for a Senior Nurse Reviewer to perform reviews of medical records, healthcare claims, itemized medical bill, and UB-04 forms to ensure accuracy, compliance, and proper billing practices. This position requires clinical review expertise, as well as itemized bill review experience. Your role in our mission involves performing an in-depth review of medical claims utilizing the UB-04 and detailed itemized statement to ensure the validity of line-item charges. You will verify the accuracy of the itemized charges in accordance with client policy and industry standards. Additionally, you will perform level of care and utilization review by analyzing medical records and comparing against criteria to determine appropriateness and reasonableness of care. This role requires applying critical thinking and decision-making skills to determine if the medical record documentation supports the need for service while maintaining production goals and quality standards. You will also assist management with training new reviewers, including daily monitoring, mentoring, feedback, and education. Maintaining current knowledge of clinical criteria guidelines and/or coding guidelines, and successfully completing required CEUs to maintain RN license is crucial. You will be responsible for attending training and scheduled meetings to enhance skills and working knowledge of clinical policies, procedures, rules, and regulations. Actively cross-training to perform reviews of multiple claim types is expected to provide a flexible workforce to meet client needs.

Requirements

Active, Unrestricted RN license from the United States and in the primary home residency, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), required
5+ years clinical experience in an inpatient hospital setting required
1+ year itemized bill review experience required
Experience with CPT, ICD-10, and HCPCS coding guidelines

Nice To Haves

3+ years utilization review experience or claims auditing preferred
Experience using MCG or InterQual criteria preferred

Responsibilities

Perform an in-depth review of medical claims utilizing the UB-04 and detailed itemized statement to ensure the validity of line-item charges.
Verify accuracy of the itemized charges in accordance with client policy and industry standards.
Perform level of care and utilization review by analyzing medical records and comparing against criteria to determine appropriateness and reasonableness of care.
Apply critical thinking and decision making skills to determine if the medical record documentation supports the need for service while maintaining production goals and quality standards.
Assists management with training new reviewers to include daily monitoring, mentoring, feedback and education.
Maintains current knowledge of clinical criteria guidelines and/or coding guidelines; successfully completes required CEUs to maintain RN license.
Responsible for attending training and scheduled meetings to enhance skills and working knowledge of clinical policies, procedures, rules, and regulations.
Actively cross-trains to perform reviews of multiple claim types to provide a flexible workforce to meet client needs.