Claims Review Nurse

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

📋 Description

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

• Review submissions, identify any missing documents, and ascertain requirements for dispute resolution.

• Acquire necessary documentation in line with established procedures.

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

• Prepare case documents and provide guidance to assigned clinical reviewers.

• Work in conjunction with the legal team to address disputes.

• Compose professional determination letters.

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

• Deliver determinations within required timeframes.

• Utilize knowledge of CPT codes.

• Participate in mandatory meetings.

• Collaborate with credentialed clinical professionals to assess medical necessity.

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

• Follow company policies, state regulations, and project guidelines diligently.

• Complete reviews within designated deadlines and adhere to QA/QC processes.

• Maintain scheduling commitments and uphold privacy regulations.

• Execute other related responsibilities as assigned by leadership.

⛳️ Requirements

• Hold an active nursing license.

• Possess five years of full-time equivalent experience in direct patient care.

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

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

• Be familiar with electronic documents such as PDFs, Microsoft Excel, Microsoft Word, and Microsoft Outlook.

• Have experience with electronic data repositories like SharePoint and/or ShareFile.

• Demonstrate exceptional skills in managing sensitive and confidential information.

• Exhibit strong organizational, written, and verbal communication skills in English.

• Ability to work both independently and collaboratively with clinical reviewers, physicians, and attorneys.

• Possess skills in prioritizing tasks based on business needs and assignments.

• Experience in appeal and/or claim dispute processes is preferred.

• Completion of a background check is required.

🏝️ Benefits

• Comprehensive health, dental, and vision insurance.

• Retirement savings plan with employer matching.

• Opportunities for professional development and continuing education.

• Flexible working hours and remote work options.

• Generous paid time off and holiday schedule.