MEDICAL CLAIMS REVIEW NURSE

VIVA USA Inc.; Phoenix (AZ); Remote; USD 60,000 - 80,000; Full time

Job summary

A healthcare service provider is seeking a Medical Claims Review Nurse to perform adjudication of claims remotely. The candidate must hold an active RN license in Arizona and have experience in behavioral health. Responsibilities include reviewing claims for medical necessity and preparing reports. The role requires strong organizational and communication skills. This position offers a full-time schedule with no overtime, and allows for remote work primarily.

Qualifications

• Active RN License in AZ is mandatory.
• Behavioral Health experience (preferably outpatient).
• Experience in healthcare delivery systems.

Responsibilities

• Perform medical claims review/adjudication using claims industry standards.
• Prepare reports and analyze savings and trends.
• Interact with departments/providers as needed.

Skills

Organizational skills

Interpretation of rules and laws

Written and communication skills

Computer skills

Utilization Review skills

Medical Claims Review skills

Research and analysis

Team player and can work independently

Education

High school diploma

Active RN license in AZ

Job description

Medical Claims Review Nurse

Phoenix, AZ (100% Remote)

Job Description

The role will be focused on the review and adjudication of the client 1500 claim forms. Some coordination will be required with medical providers for 2nd level reviews and evaluating against prior authorizations and UB claims. The candidate will need a computer which client can set up remote desktop access. The role does not currently allow for Overtime but could be approved as the client has need.

Major duties and responsibilities

• Performs medical claims review/adjudication using claims industry standards. Determines if a claim meets emergency criteria, medical necessity, and/or correct revenue code/CPT/HCPC coding. Also determines if the level of care and length of stay is appropriate for the client recipient.
• Prepares reports and analyzes savings and trends. Interacts with other departments/providers as needed.
• Performs special projects including but not limited to research projects.

Knowledge

• Medical nursing practice, medical case management protocols, quality management and utilization review protocols as related to all populations including Maternal and Child Health services, preventive health, family planning, sterilization, and pregnancy termination, EPSDT, acute, LTC, chronic long-term elderly and physical disabled, developmentally disabled, behavioral/mental health, and Tribal
• Healthcare delivery system nationally and locally
• Managed care processes
• Acute nursing processes including assessment, planning, intervention, and evaluation
• InterQual Criteria
• CCI
• Coding: CPT, HCPCS, ICD-9
• Medical Claims Review
• Statistical analysis
• Computer data retrieval and input
• Interpretation of governmental agencies
• Client Rules and Regulations
• Code of Federal Regulations

Requirements

• Active RN License in AZ
• Behavior Health experience, (Outpatient preferably)

Skills

• Organizational skills that result in prioritization of multiple tasks
• Interpretation of rules, laws and client policy pertaining to the client program
• Good written and communication skills
• Computer skills
• Utilization Review skills
• Medical Claims Review skills
• Producing work products with limited supervision
• Effectively collaborating with people in positions of all levels
• Research and analysis
• Team player and can work independently

Abilities

• Interpret and apply medical and claims policies
• Read and interpret medical documentation
• Evaluate medical documentation for emergency criteria, medical necessity, correct CPT coding
• Determine appropriate hospital levels of care and lengths of stay
• Respond to inquiries for UR/CPT coding decisions
• Maintain data for monthly reports
• Work independently with minimal supervision
• Ability to work Virtually

Experience Requirements

High school Diploma

Possession of a current license to practice as a registered nurse in AZ and experience in health care delivery systems.

Preferred

Experience in concurrent and retrospective review; CCI, lnterQual, HCPCS and CPT Coding; managed care medical review experience. Certification in CPT Coding is a plus.

Work Schedule

8:00am- 5:00pm 40hrs per week, (M-F, no weekends. No OT time). Remote, primarily remote, however candidates may need to go onsite.

VIVA is an equal opportunity employer. All qualified applicants have an equal opportunity for placement, and all employees have an equal opportunity to develop on the job. This means that VIVA will not discriminate against any employee or qualified applicant on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.