Perform medical claim reviews for medically complex services, preauthorization/predetermination requests, appeals or reconsiderations, potential fraud and/or abuse referrals, and correct coding for claims/operations
Make payment determinations using clinical medical information and established criteria, protocol sets, or clinical guidelines
Determine medical necessity, appropriateness, and reasonableness for coverage and reimbursement
Monitor process timeliness according to contractor standards
Document medical rationale supporting payment or denial of services and supplies
Educate internal and external staff on medical reviews, medical terminology, coverage determinations, and coding procedures
Participate in quality control activities supporting corporate and team-based objectives
Provide guidance, direction, and input to LPN team members
Educate non-medical staff through discussions, team meetings, classroom participation, and feedback
Assist with special projects and specialty duties assigned by management
Requirements:
Active RN licensure in the state hired, or active compact multistate RN license under the Nurse Licensure Compact (NLC)
Associate degree in Nursing or graduation from an accredited School of Nursing
Two years of clinical experience as an RN
Working knowledge of word processing software
Ability to work independently, prioritize effectively, and make sound decisions
Good judgment skills
Demonstrated customer service and organizational skills
Demonstrated oral and written communication skills
Analytical or critical thinking skills
Ability to handle confidential or sensitive information with discretion
Microsoft Office proficiency
Acute care experience required
Ability to use multiple Windows-based programs simultaneously preferred
Three years of varied RN nursing experience, including Medical/Utilization Review, Quality Assurance, Emergency, Critical Care, or Medical/Surgical experience, strongly preferred
Medicare or claims experience a plus
Critical care experience preferred
Medical review/utilization review experience preferred
Benefits:
Subsidized health plans
Dental and vision coverage
401k retirement savings plan with company match
Life Insurance
Paid Time Off (PTO)
On-site cafeterias and fitness centers in major locations
Education Assistance
Service Recognition
National discounts to movies, theaters, zoos, theme parks and more
Reasonable accommodations for disabilities, pregnancy-related conditions, and sincerely held religious beliefs
Pay differential coverage for full-time employees in the National Guard or Reserves called to active duty