Claims Review Nurse — Disputes & IRO Expert

Capitol Bridge, Llc

Virginia

Sur place

USD 75 000 - 85 000

Plein temps

14 jours+

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Résumé du poste

Capitol Bridge LLC, based in Arlington, Virginia, seeks an experienced Claims Review Nurse to support the Florida CDR program and independent review initiatives across states. You will assess documentation, assign clinical reviewers, draft determinations, and work with legal teams to resolve disputes involving physicians, hospitals, and payers.

The ideal candidate holds an active US nursing license (non-restricted) with at least five years of direct patient care and demonstrates strong

Qualifications

Active nursing license in any US state.
Five years of full-time equivalent direct patient care.
Non-restricted nursing license.
Ability to pass a background check.
Strong written and verbal communication and documentation skills.

Responsabilités

Conduct an initial assessment of documentation from both initiating and responding parties.
Review submitted documentation to identify missing items and obtain required documents.
Determine the appropriate type of clinical reviewer (e.g., medical coder, 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 providers to resolve disputes.
Ensure timely delivery of determinations and adhere to deadlines.
Familiarity with CPT codes and relevant guidelines to support determinations.
Attend required meetings and follow QA/QC processes.