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Medical Claim Review Nurse

Integrated Resources, Inc

Phoenix, AZ(remote)

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JOB DETAILS
SKILLS
Analysis Skills, Auditing, Billing, Biotech and Pharmaceutical, CMOS, Claims Processing, Clinical Medicine, Clinical Nursing, Clinical Practices/Protocols, Clinical Support, Clinical Validation, Code Reviews, Communication Skills, Detail Oriented, Diagnosis-Related Group (DRG), Documentation Review, Federal Laws and Regulations, Healthcare, Insurance, Legal Support Skills, Licensed Practical Nurse/Licensed Vocational Nurse, Managed Care, Medical Billing, Medical Coding, Medical Records, Microsoft Office, Nursing, On Call, Outpatient Care, Patient Care, Patient Care Denials, Presentation/Verbal Skills, Problem Solving Skills, Quality of Care, Registered Nurse (RN), Regulations, Regulatory Requirements, Reimbursement, Resolve Customer Issues, Resource Management, Resource Utilization, Special Needs, State Laws and Regulations, Time Management, Training/Teaching, Utilization Management, Writing Skills
LOCATION
Phoenix, AZ(remote)
POSTED
4 days ago
Fully Remote -
Fully Remote - YES, candidates should be in Client, FL, ID, IA, GA, KY, MI, NE, NM, OH, TX, UT, WI, WA, SC, NY, AZ, MS

What is the expected schedule (include dates/time/time zone): 9-5 PST
Must work on alternate weekends.
Weekend rotation sat and they have Monday off prior to the weekend.
They work a full day Saturday and on call Sunday.

Day to Day Responsibilities:
Utilizing clinical knowledge and experience, responsible for review of documentation to ensure medical necessity and appropriate level of care utilizing ClientG/InterQual, state/federal guidelines, billing and coding regulations, and Client policies; validates the medical record and claim submitted support correct coding to ensure appropriate reimbursement to providers.

Must Have Requirements
Preservice experience, some managed care experience, utilization management and preferably in appeals and grievances.
Is there potential for this to extend past 6 months and/or convert to an FTE?: Yes

Summary:
  • Facilitates medical review of prospective, retrospective, and concurrent review of appeals for denied prior authorizations. Includes standard and expedited cases, inpatient, outpatient, and pharmaceutical authorization appeals.
  • Facilitates clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases in which an appeal has been made, or is likely to be made, to ensure medical necessity and appropriate/accurate billing and claims processing.
  • Reevaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of relevant and applicable state and federal regulatory requirements and guidelines, knowledge of Client 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-related group (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 cases representing Client, 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 Client program per applicable policies/protocols.
  • Facilitates medical review of prospective, retrospective, and concurrent review of appeals for denied prior authorizations. Includes standard and expedited cases, inpatient, outpatient, and pharmaceutical authorization appeals.
  • Facilitates clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases in which an appeal has been made, or is likely to be made, to ensure medical necessity and appropriate/accurate billing and claims processing.
  • Reevaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of relevant and applicable state and federal regulatory requirements and guidelines, knowledge of Client 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-related group (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 cases representing Client, 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 Client program per applicable policies/protocols.

Must Have Skills:
  • Analytic, problem-solving, and decision-making skills.
  • Organizational and time-management skills.
  • Attention to detail.
  • Critical-thinking and active listening skills.
  • Common look proficiency.
  • Effective verbal and written communication skills.
  • Microsoft Office suite and applicable software program(s) proficiency.
  • Experience demonstrating knowledge of ICD-10, Current Procedural Technology (CPT) coding and
  • Healthcare Common Procedure Coding (HCPC).
  • Experience working within applicable state, federal, and third-party regulations.

Required Years of Experience:
At least 2 years clinical nursing experience, including at least 1 year of utilization review (prospective, retrospective and concurrent clinical 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.

Required Licensure / Education:
Registered Nurse (RN)/Licensed Practical Nurse (LPN) License must be active and unrestricted in state of practice.
Compact license is acceptable where states allow.

About the Company

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Integrated Resources, Inc

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