Clinical Claims Reviewer, RN

Jobtailor; Deutschland; Remote; EUR 60.000 - 86.000; Vollzeit

Zusammenfassung

Jobtailor seeks an experienced RN for Utilization Management and Medical Coding review. You will perform utilization management services, conduct comprehensive pre- and post-payment claim reviews, and assess inpatient, outpatient, concurrent, and retrospective authorization cases while ensuring compliance with health plan policies and regulatory requirements.

You will address provider inquiries, refer cases to Medical Directors, and support accreditation efforts by applying accrediting

Qualifikationen

• RN BSN and Bachelor's Degree in Nursing are required.
• Registered Nurse license (Compact or Virginia) required.
• 3 years of acute care clinical experience required.
• Medical Coding certification required within 1 year of hire.

Aufgaben

• Perform utilization management services within licensure.
• Conduct comprehensive pre- and post-payment claim reviews.
• Review inpatient, outpatient, concurrent, and retrospective authorization cases.
• Address provider post-payment inquiries and reconsiderations.
• Refer cases to Medical Directors as appropriate.
• Ensure compliance with health plan policies and regulatory requirements.

Kenntnisse

Utilization Management

Medical Coding

Claim Review

Post-Payment Review

Accreditation Knowledge

NCQA Knowledge

Provider Communication

Regulatory Compliance

Ausbildung

Bachelor's Degree in Nursing

RN BSN

Tools

MCG

CMS

BOI

Virginia DMAS

Jobbeschreibung

• Perform utilization management services within the scope of licensure
• Conduct comprehensive pre- and post-payment claim reviews
• Review inpatient, outpatient, concurrent, and retrospective authorization cases
• Address provider post-payment inquiries and reconsiderations
• Refer cases to Medical Directors as appropriate
• Ensure compliance with health plan policies and regulatory requirements, including BOI, NCQA, CMS, and Virginia DMAS
• Review member eligibility and benefits, medical policy, vendor guidelines, MCG, DMAS, and CMS criteria
• Provide written notification of review decisions to providers
• Facilitate accreditation by interpreting and applying accrediting and regulatory standards
• Review claim reconsiderations for accurate coding
• Evaluate code selection, modifiers, code bundling, unlisted codes, excessive procedures, diagnosis compatibility, frequency limits, and other coding edits
• Apply clinical knowledge and coding expertise to promote compliance, accuracy, and appropriate reimbursement

Requirements

• RN BSN required
• Bachelor's Degree in Nursing required
• Registered Nurse (RN) License (Compact or Virginia) required
• 3 years of acute care clinical experience required
• Medical Coding certification required within 1 year of hire
• Previous Utilization Review and Post Payment Review a plus
• MCG experience preferred
• Knowledge of NCQA preferred
• Strong verbal, written and interpersonal communication skills
• Problem solving skills
• Facilitation skills
• Analytic skills
• Certified Professional Coder (CPC) preferred
• Health Plan experience preferred
• Claims or post payment reconsideration experience preferred
• Standard working hours availability: 8am to 5pm EST, Monday-Friday
• Remote work available 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

Core Competencies

Demonstrates expertise in Utilization Management and Medical Coding, ensuring compliance with health plan policies and regulatory standards. Proficient in conducting comprehensive claim reviews and applying clinical knowledge to promote accurate reimbursement.

Highest-signal resume keywords

• Utilization Management
• Medical Coding Certification
• Registered Nurse (RN) License
• Acute Care Clinical Experience
• NCQA Knowledge

Hard Skills

• Claim Review
• Coding Expertise
• Pre- and Post-Payment Review
• Diagnosis Compatibility Evaluation
• Coding Edits Application

Soft Skills

• Verbal Communication
• Written Communication
• Interpersonal Skills
• Problem Solving
• Facilitation Skills

Certifications & Qualifications

• RN BSN
• Medical Coding Certification
• Certified Professional Coder (CPC)

Industry Keywords

• Health Plan Compliance
• Accreditation Standards
• Claims Reconsideration
• Provider Inquiries

Tools & Technologies

• MCG
• CMS
• BOI
• Virginia DMAS