Clinical Claims Reviewer, RN

This is a fully remote position, open to applicants in Alabama, +25 more states.

📋 Description

• Deliver utilization management services within the boundaries of licensure.

• Execute thorough pre- and post-payment claim assessments.

• Analyze inpatient, outpatient, concurrent, and retrospective authorization cases.

• Respond to provider post-payment inquiries and requests for reconsideration.

• Escalate cases to Medical Directors as necessary.

• Ensure adherence to health plan policies and regulatory standards, including BOI, NCQA, CMS, and Virginia DMAS.

• Assess member eligibility and benefits, medical policy, vendor guidelines, MCG, DMAS, and CMS criteria.

• Issue written notifications of review outcomes to providers.

• Support accreditation by interpreting and applying relevant accrediting and regulatory standards.

• Examine claim reconsiderations for proper coding.

• Assess code selection, modifiers, code bundling, unlisted codes, excessive procedures, diagnosis compatibility, frequency limits, and other coding adjustments.

• Utilize clinical knowledge and coding proficiency to enhance compliance, accuracy, and appropriate reimbursement.

⛳️ Requirements

• RN BSN is mandatory.

• A Bachelor's Degree in Nursing is required.

• Registered Nurse (RN) License (Compact or Virginia) is essential.

• Minimum of 3 years of acute care clinical experience is required.

• Medical Coding certification must be obtained within 1 year of hiring.

• Previous experience in Utilization Review and Post Payment Review is an advantage.

• MCG experience is preferred.

• Familiarity with NCQA is preferred.

• Excellent verbal, written, and interpersonal communication abilities are essential.

• Strong problem-solving capabilities.

• Facilitation skills are required.

• Analytical skills are necessary.

• Certified Professional Coder (CPC) certification is preferred.

• Experience in Health Plans is preferred.

• Experience with claims or post-payment reconsideration is preferred.

• Availability during standard working hours: 8am to 5pm EST, Monday to Friday.

• Remote work options are available for residents in Virginia, North Carolina, Alabama, Delaware, Florida, Georgia, Idaho, Indiana, Kansas, Louisiana, Maine, Maryland, Minnesota, Nebraska, Nevada, New Hampshire, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Washington, West Virginia, Wisconsin, or Wyoming.

🏝️ Benefits

• Medical, Dental, and Vision insurance plans.

• Adoption, Fertility, and Surrogacy Reimbursement up to $10,000.

• Paid Time Off and Sick Leave.

• Paid Parental & Family Caregiver Leave.

• Emergency Backup Care services.

• Long-Term, Short-Term Disability, and Critical Illness insurance plans.

• Life Insurance coverage.

• 401k/403B plan with Employer Match.

• Tuition Assistance of $5,250/year along with discounted educational opportunities through Guild Education.

• Student Debt Pay Down benefit of $10,000.

• Pet Insurance availability.

• Access to Legal Resources Plan.

• Potential to earn an annual discretionary bonus if established system and employee eligibility criteria are met.

• Competitive compensation packages, inclusive of incentives and benefits.

• Family-friendly culture that promotes community involvement, development, and growth opportunities.

• Tobacco-free workplace environment.