IDR Nurse Reviewer

About the role

The Nurse Reviewer position supports and conducts reviews and determinations for independent dispute resolutions at both the Federal and State levels. This role involves analyzing medical records, ensuring proper documentation, and providing quality assurance checks to support the final determination.

Responsibilities

• Conduct an initial assessment of documentation from both the initiating and responding parties.
• Review submitted documentation to identify missing documents and determine what is required to resolve the dispute.
• Follow procedures to obtain the appropriate documentation.
• Determine the appropriate type of clinical reviewer necessary to complete the case, such as a medical coder or a physician.
• Prepare documents for the arbitrator reviewer assigned and provide instructions as needed.
• Collaborate with the legal team to facilitate resolution of disputes.
• Draft professional determination correspondence.
• Perform quality assurance checks on determinations according to Federal or State guidance.
• Audit and analyze patient records to ensure appropriate determination.
• Stay current with regulation changes and perform research on a case-by-case basis.
• Deliver high-quality, professional determinations free of grammar and spelling errors.
• Amend reports with additional clinical information when necessary.
• Participate in an interdisciplinary health care team to achieve positive outcomes.

Requirements

• Maintain an active license in nursing (at a minimum, RN required)
• Five years of full-time equivalent experience providing direct care to patients
• Hold a non-restricted nursing license in any state in the US.
• Ability to analyze clinical documentation and apply appropriate guidelines
• Strong oral and written communication skills with excellent customer service
• Ability to multitask and adapt to a fast-paced environment
• Strong organizational skills and attention to detail
• Knowledge of claim review processes includes billing, Current Procedural Terminology (CPT) coding, and Explanation of Benefits
• Familiarization with navigating electronic documents like PDFs, Microsoft Excel, Microsoft Word, and experience using Microsoft Outlook
• Familiarization with electronic data repositories such as SharePoint and/or ShareFile
• Exceptional skills in managing sensitive and confidential information
• Strong organizational abilities, written, and verbal communication skills in English
• Ability to work both independently and collaboratively with other team members to include clinical reviewers, physicians, and attorneys
• Skilled in prioritizing tasks to align with business needs and assignments
• Appeal and/or claim dispute-related experience
• Medical Coding Certification preferred
• Experience with Utilization Review preferred

Qualifications

• Maintain an active license in nursing (at a minimum, RN required)
• Five years of full-time equivalent experience providing direct care to patients
• Hold a non-restricted nursing license in any state in the US.

Skills

• Ability to analyze clinical documentation and apply appropriate guidelines
• Strong oral and written communication skills with excellent customer service
• Ability to multitask and adapt to a fast-paced environment
• Strong organizational skills and attention to detail
• Knowledge of claim review processes includes billing, Current Procedural Terminology (CPT) coding, and Explanation of Benefits
• Familiarization with navigating electronic documents like PDFs, Microsoft Excel, Microsoft Word, and experience using Microsoft Outlook
• Familiarization with electronic data repositories such as SharePoint and/or ShareFile
• Exceptional skills in managing sensitive and confidential information
• Strong organizational abilities, written, and verbal communication skills in English
• Ability to work both independently and collaboratively with other team members to include clinical reviewers, physicians, and attorneys
• Skilled in prioritizing tasks to align with business needs and assignments
• Appeal and/or claim dispute-related experience
• Medical Coding Certification preferred
• Experience with Utilization Review preferred

Benefits

This position requires established, professional relationships with internal personnel at all levels within the company and with beneficiaries, representatives, providers, and other stakeholders.

Pay

$45-$55/hr

Schedule

Schedules may vary and may include weekend and holiday shifts.