Nurse Reviewer RN

FHAS Federal Hearings & Appeals Services, Inc.; Wilkes-Barre (Luzerne County); On-site; USD 67,500 - 95,000; Full time

Job summary

FHAS Federal Hearings & Appeals Services, Inc. is seeking a Nurse Reviewer RN for a full-time on-site role in Wilkes-Barre, PA.

The position focuses on timely review and determination of medical claims, appeals, and prior authorizations, with emphasis on accurate coding review and adherence to Medicare regulations. The ideal candidate holds an active RN license, has 1+ years of clinical experience, and preferably a coding certification.

Qualifications

• Must possess a current, unrestricted State RN license.
• 1+ years clinical experience required; coding, utilization, and/or medical chart review preferred.
• Professional Coding Certification preferred.
• Knowledge of Medicare regulations and guidelines, policies, and payor reimbursements preferred.
• Knowledge of CPT, HCPCS, ICD-10 codes and coding guidelines.
• Ability to identify Medicare billing and payment irregularities.
• Strong analytical, written and oral communication skills.
• Excellent organizational skills and teamwork.
• Limited travel may be required.

Responsibilities

• Provide timely review and determination of medical claims, including prior authorization, appeals, and other 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 relevant documentation.
• Adjudicate claims based on regulations and documentation.
• Attend FHAS and client training sessions on site as needed.
• Complete IRR surveys promptly and maintain high quality scores.

Skills

Analytical skills

Verbal & written communication

Team player

Attention to detail

Education

RN license

Tools

PC proficiency

EMR/medical coding systems

Job description

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 RN

Full Time PA, Wilkes-Barre, PA, US

3 days ago Requisition ID: 1024

Salary Range: $67,500.00 To $95,000.00 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 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