Remote Clinical Claims Reviewer (RN)

SCAN Health Insurance; Oregon; Hybrid; USD 53.000 - 77.000; Vollzeit

Benefits dieser Stelle

Annual bonus program

Wellness Program

Generous PTO

11 paid holidays + floating + birthday

401(k) with employer match

Tuition reimbursement

Employee recognition program

Zusammenfassung

SCAN Health Insurance is seeking a Clinical Reviewer to provide clinical review of medical claims and post-service appeals, ensuring investigations align with SCAN standards. You will interpret CMS guidelines, review complex pre/post payments, and guide staff through adjudication decisions.

The role emphasizes analytical judgment, collaboration with Medical Director, and participation in cross-functional projects. Remote position with competitive hourly pay and benefits.

Qualifikationen

• Associate's degree or equivalent experience required.
• Current and active California RN License in good standing required.
• Bachelor's Degree or equivalent experience preferred.
• 3-5 years of related experience in clinical decision making relative to Medicare patients.
• Certifications deemed to be reasonable to function at this level.

Aufgaben

• Review and analyze pre and post payment of complex health care claims from a medical perspective.
• Perform audits/reviews of medical claims per established criteria, identify need for medical record review, necessary documentation to support decision making process regarding appropriateness of claim, billed charges, benefit coverages
• Provide guidance to other staff members and accurately interpret and apply CMS guidelines to specific situations
• Conduct review of claims data and medical records to make clinical decisions on coverage, medical necessity, utilization, and appropriateness of care
• Process workload and complete project work in the appropriate computer system(s). Contribute to team effort by accomplishing related results as needed.
• Route identified clinical and/or risk issues to appropriate personnel e.g., Medical Director, QOC Nurse, Medical Management Specialist, Member Services, etc.
• Review/prepare potential claims denials in conjunction with Medical Director
• Collaborate with Medical Director pursuant to adjudication of claims and post service appeals
• Participate in special projects/workgroups/committees as assigned and as necessary
• We seek Rebels who are curious about AI and its power to transform how we operate and serve our members.
• Actively support the achievement of SCAN's Vision and Goals.
• Other duties as assigned.

Kenntnisse

RN License (CA)

Communication

Teamwork

Problem Solving

Attention to detail

Interpersonal skills

Oral and written communication

Ausbildung

Associate's degree or equivalent experience

Bachelor's Degree or equivalent experience preferred

Current and active California RN License

Jobbeschreibung

SCAN Health Insurance is seeking a Clinical Reviewer to provide clinical review of medical claims and post-service appeals, ensuring investigations align with SCAN standards. You will interpret CMS guidelines, review complex pre/post payments, and guide staff through adjudication decisions.

The role emphasizes analytical judgment, collaboration with Medical Director, and participation in cross-functional projects. Remote position with competitive hourly pay and benefits.