Claims Review Nurse (59493)

Capitol Bridge.; Virginia (IL); Hybrid; USD 75,000 - 85,000; Full time

Job summary

Capitol Bridge seeks an experienced Claims Review Nurse to resolve healthcare claim disputes under state IRO programs. You will evaluate documentation, coordinate with clinical reviewers, and work with health plans, providers, and enrollees to reach timely determinations with accuracy and professional integrity.

This remote position supports state-wide health plan disputes, requires active nursing licensure and at least five years of patient care experience, and emphasizes compliance with CPT

Qualifications

• Active nursing license required.
• Five years of full-time equivalent direct patient care experience.
• Non-restricted nursing license in any US state.

Responsibilities

• Conduct an initial assessment of documentation from initiating and responding parties.
• Review submitted documentation to identify missing items and obtain necessary documentation.
• Determine the appropriate clinical reviewer (e.g., medical coder or physician).
• Prepare materials for the clinical reviewer and provide guidance as needed.
• Collaborate with legal to facilitate dispute resolution and draft determinations.
• Communicate with enrollees, health plans, and providers to resolve disputes.
• Ensure timely delivery of determinations and maintain privacy rules.
• Familiarize with CPT coding and relevant guidelines as needed.
• Participate in required meetings and team coordination.

Skills

Nursing communication

English written and verbal

Claim review experience

Independent review processes

Education

Active nursing license

Non-restricted nursing license (any state)

Tools

SharePoint

ShareFile

Microsoft Excel

Microsoft Word

Microsoft Outlook

Job description

Job Details

Job Location: Remote - Remote Employees, VA 12345

About Capitol Bridge

Founded in 2012, Capitol Bridge is based in Arlington, Virginiaandhasprovenexpertiseproviding independent medical reviews, records/data management services, medical coding, administrativestaffingand eligibility reviews.

Capitol Bridge is actively seeking an experiencedClaims ReviewNurse. The Claims ReviewPositionwill play a crucial role in the Florida Statewide Health Plan Claim Dispute Resolution(FL CDR)Program under the Agency for Health Care Administrationand Independent Review Organization (IRO) programs for multiple States. This position is integral to ensuring fair and efficient resolution of claim disputes.

You willbe responsible forresolving claim disputessubmittedby various parties such as physicians, hospitals, institutions, pharmacies, and other licensed healthcare providers.

Forthe FloridaCDR program,you willassistcontracted and non-contracted health care providers and health care planswithresolution ofclaimdisputes within the parameters of Section 408.7507, Florida Statutes and Rule 59A-12.030, Florida Administrative Codes.

Additionally, your responsibilities will include resolving disputessubmittedto various State’sIndependent Review Organization (IRO)programs. IROsconduct impartial reviews of healthcare services to resolve disputes between patients, healthcare providers, and payers.IROsprovide objective assessments of medical necessity, appropriateness of care,billing, coding,and other issues related todisputed claims.Your role requires conducting all job duties efficiently, promptly, productively, consistently, and courteously, whilemaintaininga high levelof professionalism.

Salary Range:$75-85k

Key Responsibilities:

• Conductan initialassessment of documentation from boththeinitiating and responding parties.


• Reviewsubmitteddocumentation toidentifymissing documents anddeterminewhat isrequiredto resolve the dispute. Follow proceduresto obtain theappropriatedocumentation.


• Determinetheappropriate typeof clinical reviewernecessaryto complete thecase,such as a medical coder, orphysician.


• Prepare documents for the clinical reviewer assigned and provide instruction as needed.


• Collaborate with the legal team tofacilitateresolution of disputes.


• Draftprofessional determination letters.


• Communicatewith Enrollees, Health Plans, and/orProviders as neededto resolve disputes.


• Follow establishedproceduresto ensuretimelydelivery of determinations.


• FamiliarizationofCurrent Procedural Terminology (CPT)codes.


• Participation inrequiredmeetings.


• Collaborate with credentialed clinical professionalstodeterminethemedical necessity of each service/procedure at issue in a dispute.


• Utilizegovernmental andprofessionalguidelines to supportthedeterminationontheappropriateness of each service/procedure listed in a dispute.


• Adhere to company policies, state regulations, and specific project guidelines.


• Maintain effective communication.


• Ensuretimelycompletion ofreviewswithin assigned deadlines.


• Follow establishedQuality Assurance/Quality Controlprocesses and meet company/departmental standards.


• Uphold scheduling commitments and privacy regulations.


• Perform other related duties as directed by leadership.

Required Screenings

You will receive a request for a background checkregardingthis employment opportunity. Employment is contingent on successful passing of a background check.

Reasonable Accommodation

If you require alternative methods of application or screening, you must approach the employer directly to request this. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed are representative of the knowledge, skill, and/or abilityrequired. Reasonable accommodation may bemadeto enable individuals with disabilities to perform essential functions. Other duties may be assigned.

EEO Statement

CapitolBridgeLLC. is an Equal Opportunity Employer. All employment decisions at Capitol Bridge are based on business needs, job requirements, and individual qualifications,without regard to race, color, religion or belief, national, social, or ethnic origin, sex (including pregnancy), age, physical, mental or sensory disability, HIV Status, sexual orientation, gender identity and/or expression, marital, civil union or domestic partnership status, past or present military service, family medical history or genetic information, family or parental status, or any other status protected by the laws or regulations in the locations where we operate.

Texting Notice

We communicate with applicants by text in addition to email and phone.If you apply for this position, we may text you about this position, your application for the position, or other things relevant tothis jobposition.If we text you and you no longer want us to text you, you can opt-out at that time.

Qualifications Required Qualification

• Maintain an active licenseinnursing.


• Five yearsoffull-time equivalent experience providing direct care to patients.


• Hold a non-restrictednursinglicense in any state in the US.

Preferred Qualifications

• Knowledge of claim reviewprocessesinclude billing,Current Procedural Terminology(CPT) coding, and Explanation of Benefits.


• Familiarization with navigating electronic documents like PDFs, MicrosoftExcel,MicrosoftWord, and experience usingMicrosoftOutlook.


• Familiarization withelectronic data repositories such asSharePoint and/orShareFile.


• Exceptional skills in managing sensitive and confidential information.


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


• Ability to work both independently and collaborativelywith other team members to include clinical reviewers,physicians,and attorneys.


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


• Appeal and/orclaimdispute related experience.