Remote Medical Policy Review RN

The Judge Group; Newark (NJ); Remote; USD 80,000 - 100,000; Full time

Job summary

An innovative firm is seeking a dedicated Medical Policy Review Specialist to join their remote team. This role is pivotal in ensuring the efficient utilization of medical benefits, where you'll analyze and recommend medical policies based on claims and cases. With a focus on compliance and accuracy, you'll interact with policy teams and manage inquiries while staying updated on relevant laws and regulations. If you're passionate about making a difference in healthcare policy and have a strong clinical background, this opportunity is perfect for you.

Qualifications

• Must reside in NJ, PA, NY, DE, or CT.
• Active RN license in NJ required.
• Minimum 3 years RN experience in a clinical setting.

Responsibilities

• Provide timely responses to inquiries from claim policy teams.
• Prepare cases for Medical Director Review.
• Identify opportunities for policy development based on case review.

Skills

Clinical RN Experience

Claims Systems

Coding Experience

Microsoft Office Skills

Education

Active NJ RN License

3+ Years RN Experience

Job description

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Location: NEWARK, NJ, USA

Salary: $35.00 USD Hourly - $39.00 USD Hourly

Job Description

The Judge Group is currently seeking a remote Medical Policy Review RN for a fantastic client of ours!

Are you passionate about ensuring appropriate and efficient utilization of medical benefits? Join our team as a Medical Policy Review Specialist, where you'll play a crucial role in the medical policy determination of claims and cases consistent with Plan Medical Policy. You'll also be responsible for researching and analyzing medical techniques, procedures, and products, and making recommendations for draft medical policy.

Job Title

Medical Policy Determination Specialist

Location

Remote but must reside in NJ, PA, NY, DE, or CT and have an active RN license in NJ

Responsibilities

• Provide timely and accurate responses to inquiries from the claim policy teams regarding courtesy pre-d requests, claims pending for medical review, and appeal inquiries.
• Prepare cases for Medical Director Review and/or outside consultant review and response where appropriate.
• Process pends for which the Medical Policy Inquiry Resolution team has authority.
• Identify opportunities for development or revisions based on case review.
• Identify areas and pursue solutions where medical policy is not being applied correctly in claim payment outcomes.
• Manage inventory, document production in RMRS, and follow through on all inquiries.
• Stay updated on mandates, policy changes, and workflow changes impacting outcomes.
• Perform special projects as assigned by management.
• Demonstrate knowledge of laws, regulations, and policies relevant to the organization, ensuring compliance.

Qualifications

• Reside in NJ, PA, NY, DE, or CT.
• Active NJ or NJ Compact RN license.
• Minimum 3 years RN experience in a clinical setting.
• Comfortable working with Claims systems.
• Coding experience required; certification not necessary.
• Ability to work in a production-focused environment.
• Strong Microsoft skills and familiarity with intranet and internet applications.

We look forward to welcoming a dedicated professional to our team. If qualified and ready to make a difference, apply today!

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Contact: [e-mail]

This job and many more are available through The Judge Group. Find us on the web at www.judge.com