Nurse Reviewer LPN

Federal Hearings and Appeals Services, LLC; Wilkes-Barre (Luzerne County); Sur place; USD 68 000 - 75 000; Plein temps

Résumé du poste

Federal Hearings and Appeals Services, LLC is seeking a Nurse Reviewer LPN in Wilkes-Barre, PA to perform timely review and determination of Medicare-related medical claims, including appeals and prior authorizations. The role requires an active LPN license, at least 1 year of clinical experience, and knowledge of CPT/HCPCS/ICD-10 coding.

On-site work with limited travel may be required. The ideal candidate will have strong analytical, written and verbal skills, and may hold CPC/CCS

Qualifications

• Current, unrestricted State LPN license.
• Minimum 1 year of clinical experience.
• Knowledge of CPT/HCPCS/ICD-10 coding is preferred.
• Professional coding certification preferred.
• Strong analytical, written and oral communication skills.
• Ability to review Medicare regulations and payor guidelines.

Responsabilités

• Provide timely review and determination of medical claims, including prior authorization, appeals, and other types of medical claims.
• Analyze medical records related to case file.
• Review and interpret LCD, NCD policies, and other federal regulations.
• Apply regulatory citations to each claim as it relates to the item.
• Formulate a narrative decision citing applicable documentation.
• Adjudicate claims based on regulations and documentation.
• Maintain licensure in active status as required by state.
• Attend FHAS and client training sessions on site as needed.
• Complete IRR surveys in a timely fashion.
• Maintain a 97% or higher quality score.

Connaissances

Analytical skills

Written and verbal communication

Team player

Attention to detail

PC proficiency

Formation

LPN license

CPC or CCS certification preferred

Description du poste

If you are unable to complete this application due to a disability, contact this employer to ask for an accommodation or an alternative application process.

Nurse Reviewer LPN

30 - Medicare- Overhead Full Time PA, Wilkes-Barre, PA, US

3 days ago Requisition ID: 1032

Salary Range: $67,500.00 To $75,000.00 Annually

• Provide timely review and determination of medical claims, including prior authorization, appeals, and/or any other type of medical claims;
• Provide timely review and determination of medical claims;
• Analyze medical records related to the case file;
• Review and interpret Local Coverage Determination (LCD), National Coverage Determination (NCD) policies, and other federal regulations;
• Apply appropriate regulatory citations, including health plan policies, NCD/LCDs, and/or other regulations to each claim as it relates to the item or issue;
• Formulate a narrative decision citing relevant regulatory back-up documentation contained within the medical record;
• Adjudicate claim based on the regulations and documentation contained within the medical record;
• Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) certification through the American Academy of Professional Coders (AAPC) or AHIMA preferred;
• Maintain professional licensure in active and unrestricted status as required by state of issuance;
• Attend FHAS and/or client Lunch & Learn sessions and/or general training sessions on site as needed.
• Complete IRR surveys in a timely fashion as required by the prime contractor
• Maintain a 97% or higher quality score

work experience requirements

• Must possess a current, unrestricted State license as an LPN,as required by contract(s).
• 1+ years clinical experience required; coding, utilization, and/or medical chart review preferred.
• Professional Coding Certification preferred.
• Detailed knowledge of Medicare regulations and guidelines, polices, and payor reimbursements preferred.
• Knowledge of CPT, HCPCS, ICD-10 codes and coding guidelines.
• Ability to identify Medicare billing and payment irregularities.
• Must be able to support review findings by utilizing exceptional analytical, written and oral communication skills.
• Ethical, self-motivated and results oriented team player.
• Strong analytical, verbal and written communication skills.
• Outstanding people skills and ability to effectively review findings /results with management.
• Must be proficient with PC and related software programs.
• Excellent organizational skills.
• Must be a team player.
• Limited travel may be required.

physical requirements

• Must be able to remain in the stationary position 95% of the time
• Constantly operate a computer and other office equipment such as telephone
• Regular & predictable attendance is essential for this position