Bill Review Nurse

Summit; United States; Hybrid; USD 90,000 - 130,000; Full time

Job summary

Summit is seeking an experienced healthcare professional for a senior role in case management. The position requires an RN license, a bachelor’s degree in healthcare management or nursing, and at least 14 years in case management or managed care.

The role includes reviewing bills, negotiating pre-surgical services, and providing expert guidance to Claims staff. The role offers a mix of on-site and remote work, with core in-office days and flexibility based on business needs.

Qualifications

• RN required.
• 14+ years of case management or managed care experience.
• Must have bill review experience.

Responsibilities

• Reviews facility and professional bills for appropriateness or inconsistencies.
• Negotiates pre-surgical services.
• Performs audits to identify leakage or improve processes.
• Provides professional advice to Claims staff on medical/cost-control procedures.
• Provides technical advice to lower-level staff and other areas.
• Assists with special projects as needed.
• May coach staff and participate in talent decisions for direct reports.
• Performs other duties as assigned.

Skills

RN

Case management

Managed care

Leadership

Education

Bachelor’s degree in Healthcare Management/Nursing/related field

Job description

Essential Job Functions and Responsibilities

• Reviews Facility and Professional bills as it compares with medical records, diagnosis & agreements for appropriateness or inconsistencies.
• Negotiates Pre-Surgical Services.
• Performs audits seeking potential leakage and/or system or procedural improvements.
• Provides professional advice and expertise to Claims staff in developing and providing medical and cost control procedures.
• Provides technical advice to lower-level associates and other functional areas.
• Assists with special projects as needed
• May have responsibility for performance and coaching of staff and may have a participatory role in decisions regarding talent selection, development, and performance management for direct reports.
• Performs other duties as assigned.
• Great American’s culture is built on connection, shared learning, and strong relationships. To support this, employees in this role are expected to be on-site four days a week, with the flexibility to work one day remote. Core in-office days are Tuesday–Thursday, with the fourth day determined by business needs.
• Must have bill review experience.
• The person hired for this position may work full-time remote depending on availability.

Job Requirements

Education: Bachelor’s degree in Healthcare Management, Nursing, or a related field. R.N. (Registered Nurse) required.

Experience: Generally, a minimum of 14 years of case management or managed care experience.

Scope of Job/Qualifications: Expert knowledge of managed care laws and regulations. Advanced ability to identify and address nuanced details that may impact the effective management of a case.  ... [expanded text].