Nurse Reviewer, RN

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

📋 Description

• Conduct prompt evaluations and determinations of medical claims, encompassing prior authorization, appeals, and various types of medical claims;

• Examine medical records pertinent to the case file;

• Assess and interpret Local Coverage Determination (LCD), National Coverage Determination (NCD) policies, along with other federal regulations;

• Apply relevant regulatory citations, including health plan policies, NCD/LCDs, and additional regulations to each claim in relation to the item or issue;

• Develop a narrative decision referencing pertinent regulatory backup documentation found within the medical record;

• Adjudicate claims based on regulations and the documentation available in the medical record;

• Participate in FHAS and/or client Lunch & Learn sessions and/or general training sessions on-site as required.

• Complete IRR surveys promptly as mandated by the prime contractor while maintaining a quality score of 97% or higher.

⛳️ Requirements

• Minimum of 1 year of clinical experience is required; coding, utilization, and/or medical chart review experience 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.

• Capability to identify discrepancies in Medicare billing and payments.

• Must demonstrate exceptional analytical, written, and oral communication skills to support review findings.

• Ethical, self-driven, and results-oriented team player.

• Strong analytical abilities along with excellent verbal and written communication skills.

• Exceptional interpersonal skills with the ability to effectively communicate findings/results to management.

• Proficient in PC and associated software applications.

• Excellent organizational capabilities.

• Must be a collaborative team member.

• Current, unrestricted State license as a Registered Nurse (RN) is required by contract(s).

🏝️ Benefits

• Comprehensive health insurance options.

• Retirement savings plan with employer matching.

• Opportunities for professional development and continuing education.

• Flexible work schedules to promote work-life balance.