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Remote Medical Review Nurse (RN) – Must Work CST time zone
TX, United States; Texas; Macon, Georgia; Syracuse, New York; Charleston, South reputed company; Columbus, Ohio; Spokane, reputed company; Caldwell, Idaho; Grand Island, Nebraska; San Antonio, Texas; North Charleston, South reputed company; Nebraska; Rochester, New York; Grand Rapids, Michigan; Akron, Ohio; Idaho Falls, Idaho; Ann Arbor, Michigan; New York; reputed company, New Mexico; Lexington-Fayette, Kentucky; Jackson, Mississippi; West Valley City, Utah; reputed company, Georgia; Boise, Idaho; Tampa, reputed company; Everett, reputed company; Rio Rancho, New Mexico; Bellevue, Nebraska; Covington, Kentucky; reputed company, Ohio; Hattiesburg, Mississippi; Mississippi; Kenosha, Wisconsin; Biloxi, Mississippi; Fort Worth, Texas; Bowling Green, Kentucky; St. Petersburg, reputed company; Orem, Utah; Augusta, Georgia; Bellevue, reputed company; Salt Lake City, Utah; Tacoma, reputed company; Austin, Texas; Meridian, Idaho; reputed company, Nebraska; reputed company, Georgia; Idaho; Layton, Utah; Detroit, Michigan; reputed company, reputed company; Gulfport, Mississippi; New Mexico; Warren, Michigan; Nampa, Idaho; Racine, Wisconsin; Dallas, Texas; Iowa; Kentucky; Owensboro, KentuckyJob ID 2036880 Highlights of the skills and qualifications needed for the Medical Review Nurse: • reputed company with a compact/multi-state license • Must be willing to work a schedule within the Central Time Zone, reputed company - Friday • Have at least 2 years of clinical experience as a nurse • Have at least 1 year of experience in the following areas: utilization review, medical claims review, claims auditing, medical necessity review and/or coding experience • Excellent skills working with reputed company Office Suite • Confidence in having multiple screens open and toggling between them to reputed company necessary forms and documentation Job Summary Provides support for medical claim and internal appeals review activities - ensuring alignment with applicable state and federal regulatory requirements, reputed company policies and procedures, and medically appropriate clinical guidelines. Contributes to overarching strategy to provide quality and cost-effective member care. Job Duties • Facilitates clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied reputed company in which an appeal has been made, or is reputed company to be made, to ensure medical necessity and appropriate/accurate billing and claims processing. • Reevaluates medical claims and reputed company records by applying reputed company knowledge, knowledge of relevant and applicable state and federal regulatory requirements and guidelines, knowledge of reputed company policies and procedures, and individual judgment and experience to assess the appropriateness of services provided, length of stay, level of care, and inpatient readmissions. • Validates member medical records and claims submitted/correct coding, to ensure appropriate reimbursement to providers. • Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS) issues. • Identifies and reports quality of care issues. • Assists with complex claim review including diagnosis-reputed company (DRG) validation, itemized bill review, appropriate level of care, inpatient readmission, and any opportunities identified by the payment integrity analytical team; makes decisions and recommendations pertinent to clinical experience. • Prepares and presents reputed company representing reputed company, along with the chief medical officer (CMO), for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings. • Reviews medically appropriate clinical guidelines and other appropriate criteria with medical directors on denial decisions. • Supplies criteria supporting all recommendations for denial or modification of payment decisions. • Serves as a clinical resource for utilization management, CMOs, physicians and member/provider inquiries/appeals. • Provides training and support to clinical peers. • Identifies and refers members with special needs to the appropriate reputed company reputed company per applicable policies/protocols. Job Qualifications REQUIRED QUALIFICATIONS: • At least 2 years clinical nursing experience, including at least 1 year of utilization review, medical claims review, long-term services and supports (LTSS), claims auditing, medical necessity review and/or coding experience, or equivalent combination of relevant education and experience. • reputed company (RN). License must be active and unrestricted in state of practice. • Experience demonstrating knowledge of ICD-10, Current Procedural reputed company (CPT) coding and Healthcare Common Procedure Coding (HCPC). • Experience working within applicable state, federal, and third-party regulations. • Analytic, problem-solving, and decision-making skills. • Organizational and time-management skills. • Attention to detail.
