Nurse Reviewer, LPN

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

📋 Description

• Conduct prompt evaluations and decisions regarding medical claims, which include prior authorizations, appeals, and various other medical claims.

• Review and analyze medical records associated with case files.

• Interpret and assess Local Coverage Determination (LCD), National Coverage Determination (NCD) policies, along with other federal regulations.

• Implement appropriate regulatory citations, such as health plan policies, NCDs/LCDs, and additional regulations, for each claim.

• Develop narrative decisions that reference relevant regulatory documentation found within the medical record.

• Adjudicate claims according to regulations and the documentation present in the medical record.

• Participate in FHAS and/or client Lunch & Learn sessions and other onsite training sessions as necessary.

• Timely completion of IRR surveys as mandated by the prime contractor.

• Maintain a quality score of 97% or higher.

• Effectively communicate findings and results with management.

• Operate a computer and various office equipment, including a telephone.

⛳️ Requirements

• Certification as a Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) is preferred.

• Must maintain active and unrestricted professional licensure as required by the state of issuance.

• A current, unrestricted State license as an LPN is necessary as per contract requirements.

• A minimum of 1 year of clinical experience is required.

• Experience in coding, utilization, and/or medical chart review is preferred.

• Professional Coding Certification is preferred.

• In-depth knowledge of Medicare regulations, guidelines, policies, and payer reimbursements is preferred.

• Familiarity with CPT, HCPCS, ICD-10 codes, and coding guidelines is essential.

• Ability to identify discrepancies in Medicare billing and payments.

• Outstanding analytical, written, and verbal communication skills.

• Proficiency in PC and relevant software programs.

• Excellent organizational abilities.

• Must be a collaborative team player.

• Ability to remain in a stationary position for 95% of the time is required.

• Consistent and reliable attendance is crucial.

🏝️ Benefits

• Participate in FHAS and/or client Lunch & Learn sessions and/or other onsite training sessions as necessary.

• Limited travel may be required.