Nurse Reviewer RN

FHAS, LLC; Wilkes-Barre (Luzerne County); On-site; USD 70,000 - 100,000; Full time

Job summary

FHAS, LLC is seeking a licensed RN to review and determine medical claims, including prior authorization, appeals, and related processes. You will analyze medical records, interpret LCD/NCD policies, and cite regulations to support decisions.

An on-site role involves attending training sessions and maintaining a 97%+ quality score. Requirements include an active RN license and 1+ year of clinical experience; a Professional Coding Certification is preferred, with proficiency in CPT/HCPCS/ICD-10

Qualifications

• Analytical thinking and attention to detail.
• Excellent written and oral communication skills.
• Able to work effectively in a team.
• Excellent organizational skills.

Responsibilities

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

Skills

Analytical skills

Written communication

Oral communication

Team player

Education

Professional Coding Certification

Tools

PC software

Job description

Responsibilities

• Provide timely review and determination of medical claims, including prior authorization, appeals, and/or any other type 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
• 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

Qualifications

• 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, policies, and payer reimbursements preferred
• Knowledge of CPT, HCPCS, ICD‑10 codes and coding guidelines
• Ability to identify Medicare billing and payment irregularities
• Excellent analytical, written and oral communication skills, and ability to support review findings
• 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
• 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 a stationary position 95% of the time
• Constantly operate a computer and other office equipment such as telephone
• Regular and predictable attendance is essential for this position