Medical Claim Review Nurse - Remote - 6 Months+

Day to Day: will be reviewing medical records to determine medical necessity against Medicare, MCG and / or IQ guidelines

Performs clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases, in which an appeal has been submitted, to ensure medical necessity and appropriate/accurate billing and claims processing.
Identifies and reports quality of care issues.
Identifies and refers members with special needs to the appropriate program per
policy/protocol.
Assists with Complex Claim review; requires decision making pertinent to clinical experience
Documents clinical review summaries, bill audit findings and audit details in the database
Provides supporting documentation for denial and modification of payment decisions
Independently re-evaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of all relevant and applicable Federal and State regulatory requirements and guidelines, knowledge of policies and procedures, and individual judgment and experience to assess the appropriateness of service provided, length of stay and level of care.
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, Chief Medical Officers, Physicians, and
Member/Provider Inquiries/Appeals.
Provides training, leadership and mentoring for less experienced clinical peers and LVN, RN and
administrative support staff.
Resolves escalated complaints regarding Utilization Management and Long Term Services & Supports
issues.
Identifies and reports quality of care issues.
Prepares and presents cases in conjunction with the Chief Medical Officers Medical Directors for
Administrative Law Judge pre-hearings, State Insurance Commission, and Meet and Confers.
Represents company and presents cases effectively to Judicial Fair Hearing Officer during Fair Hearings as may be required.

JOB FUNCTION:
Responsible for administering claims payments, maintaining claim records, and providing counsel to claimants regarding coverage amount and benefit interpretation. Monitors and controls backlog and workflow of claims. Ensures that claims are settled in a timely fashion and in accordance with cost control standards.

REQUIRED EDUCATION:
RN, BSN, or Bachelor's Degree in Nursing or Health Related Field

REQUIRED EXPERIENCE:
Minimum three years clinical nursing experience.

Minimum one year Utilization Review and/or Medical
Claims Review.



REQUIRED LICENSE, CERTIFICATION, ASSOCIATION:
Active, unrestricted State Registered Nursing (RN) license in good standing.

PREFERRED EDUCATION:
Master's Degree in Nursing or Health Related Field

PREFERRED EXPERIENCE:
Nursing experience in Critical Care, Emergency Medicine, Medical Surgical, or Pediatrics. Advanced
Practice Nursing. Billing and coding experience.

PREFERRED LICENSE, CERTIFICATION, ASSOCIATION:
Certified Clinical Coder, Certified Medical Audit Specialists, Certified Case Manager , Certified
Professional Healthcare Management, Certified Professional in Healthcare Quality or other healthcare certification.