Claims Review Nurse

This is a fully remote position, open to applicants in United States.

📋 Description

• Conduct preliminary evaluations of documentation from both initiating and responding parties.

• Analyze submitted documents to identify any missing items and determine what is necessary to resolve disputes.

• Adhere to procedures for acquiring the appropriate documentation.

• Identify the suitable clinical reviewer for each case, such as a medical coder or physician.

• Prepare relevant documents and provide guidance for assigned clinical reviewers.

• Work in conjunction with the legal team to support dispute resolution efforts.

• Compose professional determination letters.

• Engage with enrollees, health plans, and providers as required.

• Follow established procedures to ensure timely delivery of determinations.

• Collaborate with credentialed clinical professionals to assess medical necessity.

• Utilize governmental and professional guidelines to evaluate the appropriateness of services and procedures.

• Comply with company policies, state regulations, and project guidelines.

• Attend mandatory meetings.

• Complete reviews within assigned timelines.

• Adhere to Quality Assurance/Quality Control processes and departmental standards.

• Maintain scheduling commitments and adhere to privacy regulations.

• Perform additional related duties as directed by leadership.

⛳️ Requirements

• Possess an active nursing license.

• Have five years of full-time equivalent experience delivering direct patient care.

• Hold a non-restricted nursing license in any state within the US.

• Proficient knowledge of claim review processes, including billing, Current Procedural Terminology (CPT) coding, and Explanation of Benefits.

• Familiarity with electronic documents, including PDFs, Microsoft Excel, Microsoft Word, and Microsoft Outlook.

• Experience with electronic data repositories such as SharePoint and/or ShareFile.

• Strong organizational skills and excellent written and verbal communication abilities in English.

• Capacity to work independently as well as collaboratively with clinical reviewers, physicians, and attorneys.

• Ability to prioritize tasks based on business needs and assignments.

• Experience with appeals and/or claim disputes is preferred.

• Successful completion of a background check is mandatory.

🏝️ Benefits

• Background check required for employment.

• Reasonable accommodations available for applicants with disabilities.

• Equal Opportunity Employer.

• Communication with applicants via text, email, and phone.