Claims Review Nurse (59863)

Paycom; Virginia, Northern (MN, KY); Hybrid; USD 75,000 - 85,000; Full time

Job summary

Capitol Bridge LLC is seeking a Claims Review Nurse to support the Florida Statewide Health Plan CDR program and other state IRO programs. The role involves assessing documentation, coordinating with clinical reviewers, and drafting determinations to resolve disputes between providers, plans, and enrollees.

The position requires an active nursing license, 5 years of direct patient care, and ability to work independently within stringent regulatory guidelines.

Qualifications

• Active nursing license in any US state.
• At least 5 years of direct patient care experience.
• Ability to work independently and collaboratively with clinical reviewers, physicians, and attorneys.

Responsibilities

• Conduct an initial assessment of documentation from both the initiating and responding parties.
• Review submitted documentation to identify missing documents and determine what is required to resolve the dispute.
• Determine the appropriate type of clinical reviewer necessary to complete the case (e.g., medical coder or physician).
• Prepare documents for the clinical reviewer and provide instruction as needed.
• Collaborate with the legal team to facilitate resolution of disputes.
• Draft professional determination letters.
• Communicate with enrollees, health plans, and/or providers to resolve disputes.
• Follow procedures to ensure timely delivery of determinations.
• Familiarize with CPT codes and applicable guidelines to support determinations.
• Maintain privacy and adhere to QA/QC processes.

Skills

Active nursing license

Clinical experience

Communication skills

Education

Nursing degree (BSN/ADN)

Tools

SharePoint

ShareFile

Excel

Outlook

Job description

# Claims Review Nurse (59863)Fully Remote • Remote - Remote Employees, VA 12345## OverviewPosition TypeFull Time## Description**About Capitol Bridge** Founded in 2012, Capitol Bridge is based in Arlington, Virginia and has proven expertise providing independent medical reviews, records/data management services, medical coding, administrative staffing and eligibility reviews.Capitol Bridge is actively seeking an experienced**Claims Review Nurse.** The Claims Review Position will play a crucial role in the Florida Statewide Health Plan Claim Dispute Resolution (FL CDR) Program under the Agency for Health Care Administration and Independent Review Organization (IRO) programs for multiple States. This position is integral to ensuring fair and efficient resolution of claim disputes.You will be responsible for resolving claim disputes submitted by various parties such as physicians, hospitals, institutions, pharmacies, and other licensed healthcare providers.For the Florida CDR program, you will assist contracted and non-contracted health care providers and health care plans with resolution of claim disputes within the parameters of Section 408.7507, Florida Statutes and Rule 59A-12.030, Florida Administrative Codes.Additionally, your responsibilities will include resolving disputes submitted to various State’s Independent Review Organization (IRO) programs. IROs conduct impartial reviews of healthcare services to resolve disputes between patients, healthcare providers, and payers. IROs provide objective assessments of medical necessity, appropriateness of care, billing, coding, and other issues related to disputed claims. Your role requires conducting all job duties efficiently, promptly, productively, consistently, and courteously, while maintaining a high level of professionalism.Salary Range: $75-85kKey Responsibilities:* Conduct an initial assessment of documentation from both the initiating and responding parties.* Review submitted documentation to identify missing documents and determine what is required to resolve the dispute. Follow procedures to obtain the appropriate documentation.* Determine the appropriate type of clinical reviewer necessary to complete the case, such as a medical coder, or physician.* Prepare documents for the clinical reviewer assigned and provide instruction as needed.* Collaborate with the legal team to facilitate resolution of disputes.* Draft professional determination letters.* Communicate with Enrollees, Health Plans, and/or Providers as needed to resolve disputes.* Follow established procedures to ensure timely delivery of determinations.* Familiarization of Current Procedural Terminology (CPT) codes.* Participation in required meetings.* Collaborate with credentialed clinical professionals to determine the medical necessity of each service/procedure at issue in a dispute.* Utilize governmental and professional guidelines to support the determination on the appropriateness of each service/procedure listed in a dispute.* Adhere to company policies, state regulations, and specific project guidelines.* Maintain effective communication.* Ensure timely completion of reviews within assigned deadlines.* Follow established Quality Assurance/Quality Control processes 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 check regarding this 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 ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform essential functions. Other duties may be assigned. **EEO Statement**Capitol Bridge LLC. 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 to this job position. If we text you and you no longer want us to text you, you can opt-out at that time.## QualificationsRequired Qualification:* Maintain an active license in nursing.* Five years of full-time equivalent experience providing direct care to patients* Hold a non-restricted nursing license in any state in the US.Preferred Qualifications:* Knowledge of claim review processes include billing, Current Procedural Terminology (CPT) coding, and Explanation of Benefits.* Familiarization with navigating electronic documents like PDFs, Microsoft Excel, Microsoft Word, and experience using Microsoft Outlook.* Familiarization with electronic data repositories such as SharePoint and/or ShareFile.* Exceptional skills in managing sensitive and confidential information.* Strong organizational abilities, written, and verbal communication skills in English.* Ability to work both independently and collaboratively with other team members to include clinical reviewers, physicians, and attorneys.* Skilled in prioritizing tasks to align with business needs and assignments.* Appeal and/or claim dispute related experience.