Clinical Review Nurse

TRISTAR Insurance Group; South Carolina; Remote; USD 70,000 - 85,000; Full time

Job summary

An established industry player is seeking a Clinical Review Nurse to join their dynamic team. This pivotal role involves auditing complex medical bills to ensure compliance with state guidelines and TRISTAR protocols. The ideal candidate will leverage their clinical experience and negotiation skills to interact with medical providers and assist in identifying billing opportunities. With a focus on professional development and a commitment to delivering quality service, this position offers a unique opportunity to make a significant impact in the field of medical billing and review. Join a forward-thinking organization that values your expertise and dedication.

Benefits

Medical Insurance

Dental Insurance

Vision Insurance

Disability Insurance

Life Insurance

401(k) Plan

Paid Time Off

Holidays

Qualifications

• Active RN or LPN/LVN license with relevant experience.
• 3+ years of Bill Audit experience in workers' compensation.
• Clinical experience in operating room or related fields.

Responsibilities

• Review and audit medical bills for compliance and appropriateness.
• Communicate with providers and negotiate high-dollar bills.
• Assist management in identifying billing opportunities.

Skills

Bill Audit Experience

Communication Skills

Negotiation Skills

Analytical Skills

Knowledge of ICD-9, ICD-10, CPT Coding

Education

High School Diploma or GED

RN License

Certified Medical Coder

Tools

Microsoft Office

Excel

Windows

Job description

Job Details

Level: Experienced

Job Location: Involuntary Remote TMC - TMC, SC

Position Type: Full Time

Education Level: High School Diploma or GED

Salary Range: $70,000.00 - $85,000.00 Salary/year

Travel Percentage: None

Job Shift: Day

Job Category: Admin - Clerical

Clinical Review Nurse

POSITION SUMMARY: The Clinical Review Nurse is responsible for auditing and reviewing complex medical bills to ensure injured workers receive appropriate, medically necessary medical services. This role also ensures clients pay for all reasonable and appropriate charges.

DUTIES AND RESPONSIBILITIES:

1. Review and analyze medical bills for compliance with State guidelines, jurisdictional pricing, and TRISTAR protocols, making adjustments as needed.
2. Audit complex medical bills to determine the appropriateness of services, charges, and medical necessity.
3. Exercise independent judgment in communications with medical providers and assist management in identifying billing opportunities.
4. Interact daily with the medical bill review team, providing resources to analysts and management.
5. Oversee specialized pharmacy review, including physician-dispensed medications and those not meeting workers' compensation guidelines.
6. Communicate with providers, employers, and claimants regarding disputed payments.
7. Evaluate and negotiate high-dollar bills not subject to fee schedule or PPO reductions.
8. Perform other duties as assigned and participate in ongoing professional development.

EQUIPMENT OPERATED/USED: Computer, fax machine, copier, printer, and other office equipment.

Qualifications

REQUIRED QUALIFICATIONS:

• Active and unencumbered professional license.
• RN preferred or LPN/LVN with relevant experience.
• At least three years of Bill Audit experience, with knowledge of workers’ compensation laws/fee schedules in most states and utilization guidelines.
• Minimum three years' clinical experience in operating room, orthopedics, ER, or related fields.
• Certified Medical Coder.

Knowledge, Skills, and Abilities:

• Clinical experience in Operating Room, Orthopedics, Neurosurgery, ER, or Occupational Health.
• Excellent communication, negotiation, and analytical skills.
• Knowledge of ICD-9, ICD-10, and CPT coding.
• Understanding of state laws and regulations regarding medical billing and review.
• Proficiency with Windows, Microsoft Office, and Excel.

Benefits:

• Medical, Dental, Vision, Disability & Life Insurance.
• 401(k) plan.
• Paid time off and holidays.

MENTAL AND PHYSICAL REQUIREMENTS: Refer to the separate attachment for detailed checklist.