Claims Review Nurse — Dispute Resolution Specialist

Capitol Bridge; Virginia (MN); On-site; USD 75,000 - 85,000; Full time

Job summary

Capitol Bridge is seeking an experienced Claims Review Nurse to support the Florida Statewide Health Plan Claim Dispute Resolution program and multiple state IRO programs. The role focuses on resolving disputes between providers, patients, and payers with emphasis on medical necessity, billing, and coding.

Responsibilities include documenting initial assessments, assembling case materials, coordinating with clinical reviewers, and ensuring timely determinations while maintaining compliance with

Qualifications

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

Responsibilities

• Assess documentation from initiating and responding parties.
• Identify missing documents and obtain what is needed to resolve the dispute.
• Determine the appropriate clinical reviewer (e.g., medical coder or physician).
• Prepare documents for the clinical reviewer and provide instructions as needed.
• Collaborate with the legal team to facilitate dispute resolution.
• Draft professional determinations for cases.

Skills

Clinical review

Medical coding knowledge

Documentation management

Education

Active nursing license

Job description

Capitol Bridge is seeking an experienced Claims Review Nurse to support the Florida Statewide Health Plan Claim Dispute Resolution program and multiple state IRO programs. The role focuses on resolving disputes between providers, patients, and payers with emphasis on medical necessity, billing, and coding.

Responsibilities include documenting initial assessments, assembling case materials, coordinating with clinical reviewers, and ensuring timely determinations while maintaining compliance with