Nurse Reviewer RN

About the role

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.

Qualifications

• Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) certification through the American Academy of Professional Coders (AAPC) or AHIMA preferred.
• Maintain professional licensure in active and unrestricted status as required by state of issuance.
• 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.

Benefits

Maintain a 97% or higher quality score work experience requirements.

Pay

Must possess a current, unrestricted State license as a Registered Nurse (RN), as required by contract(s).

1+ years clinical experience required; coding, utilization, and/or medical chart review preferred.

Professional Coding Certification preferred.

Detail 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.

Schedule

Must be able to remain in the stationary position 95% of the time. Constantly operate a computer and other office equipment such as telephone.

Physical requirements

Must be able to remain in the stationary position 95% of the time. Constantly operate a computer and other office equipment such as telephone.

Additional Information

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.

Must be proficient with PC and related software programs.

Excellent organizational skills.

Must be a team player.

May require limited travel.