Claims Review Nurse

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

📋 Description

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

• Examine documentation, pinpoint missing items, and establish requirements to address disputes.

• Adhere to procedures for acquiring necessary documentation.

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

• Prepare documentation and offer guidance for assigned clinical reviewers.

• Work in tandem with the legal team to resolve conflicts.

• Compose professional determination letters.

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

• Ensure determinations are delivered in a timely manner.

• Review CPT codes.

• Participate in mandatory meetings.

• Collaborate with credentialed clinical professionals to assess medical necessity.

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

• Adhere to company policies, state regulations, and project guidelines.

• Complete reviews within designated deadlines.

• Follow Quality Assurance/Quality Control protocols and departmental standards.

• Maintain scheduling commitments and comply with privacy regulations.

• Carry out other related duties as assigned by leadership.

⛳️ Requirements

• Possess an active nursing license.

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

• Hold a non-restricted nursing license in any U.S. state.

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

• Proficient in using PDFs, Microsoft Excel, Microsoft Word, and Microsoft Outlook.

• Familiar with electronic data storage systems such as SharePoint and/or ShareFile.

• Capable of managing sensitive and confidential information.

• Strong organizational, written, and verbal communication skills in English.

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

• Skillful in prioritizing tasks based on business needs and assignments.

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

🏝️ Benefits

• Background check required as a condition of employment.

• Reasonable accommodations available for individuals with disabilities.

• Equal Opportunity Employer.