Nurse Reviewer

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

📋 Description

• Perform an initial evaluation of documentation provided by both the initiating and responding parties.

• Examine the submitted materials to identify any missing documents and ascertain what is needed to resolve the dispute.

• Adhere to procedures for acquiring the necessary documentation.

• Identify the suitable type of clinical reviewer required to finalize the case, such as a medical coder or a physician.

• Prepare documentation for the assigned arbitrator reviewer and offer guidance as necessary.

• Work in conjunction with the legal team to aid in the resolution of disputes.

• Compose professional correspondence regarding determinations.

• Conduct quality assurance reviews on determinations in accordance with Federal or State regulations.

• Audit and evaluate patient records to ensure accurate determinations.

• Keep abreast of regulatory changes and conduct case-specific research.

• Provide high-quality, professional determinations devoid of grammatical and spelling errors.

• Update reports with additional clinical information when required.

• Engage in an interdisciplinary healthcare team to foster positive outcomes.

⛳️ Requirements

• Hold an active nursing license (minimum of RN required).

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

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

• Capability to analyze clinical documentation and apply relevant guidelines.

• Excellent oral and written communication skills, coupled with outstanding customer service.

• Proficient in multitasking and adapting to a fast-paced work environment.

• Strong organizational skills with a keen attention to detail.

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

• Familiar with navigating electronic documents such as PDFs, Microsoft Excel, Microsoft Word, and proficient in using Microsoft Outlook.

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

• Exceptional ability to manage sensitive and confidential information.

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

• Ability to work independently as well as collaboratively with team members, including clinical reviewers, physicians, and attorneys.

• Skilled in prioritizing tasks to align with business requirements and assignments.

• Experience related to appeals and/or claims disputes.

• Medical Coding Certification is preferred.

• Experience with Utilization Review is preferred.

🏝️ Benefits

• Competitive salary and compensation package.

• Opportunities for professional development and training.

• Comprehensive healthcare benefits.

• Flexible work arrangements.

• Supportive and collaborative work environment.