Nurse Reviewer RN

Federal Hearings And Appeals; United States; Remote; USD 65,000 - 95,000; Full time

Job summary

Federal Hearings And Appeals is seeking a Remote RN Claims Reviewer to evaluate medical claims, determine approvals, denials, and appeals. You will review medical records, apply Medicare regulations, and cite supporting documentation from the case file.

Responsibilities include drafting narrative decisions, coding awareness, and maintaining professional licensure with a strong emphasis on accuracy and regulatory compliance. Travel is limited and training sessions are available as needed.

Qualifications

• Must possess a current, unrestricted State RN license.
• Minimum 1+ year clinical experience; coding or chart review preferred.
• Professional coding certification preferred.
• Strong knowledge of Medicare regulations, CPT/HCPCS/ICD-10 codes.
• Ability to support findings with analytical, written and oral skills.

Responsibilities

• Provide timely review and determination of medical claims, including prior authorization and appeals.
• Analyze medical records related to the case file and apply applicable regulations.
• Review LCD/NCD and other policies; cite regulatory back-up documentation.
• Formulate narrative decisions and adjudicate claims based on records.
• Maintain licensure and participate in FHAS training sessions on site or remotely.
• Complete IRR surveys and maintain a 97%+ quality score.

Skills

Analytical skills

Written communication

Oral communication

Team player

Organizational skills

People skills

PC proficiency

Tools

PC software

Job description

• 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 a Registered Nurse (RN),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

Remote