Remote Medical Review Nurse for Medicare Claims

SCAN Health Plan; Long Beach (CA); A distancia; USD 53.000 - 77.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Remote position

Annual bonus program

Wellness program

PTO and holidays

401(k) retirement savings with match

Tuition reimbursement

Descripción de la vacante

SCAN Health Plan is hiring a registered nurse for clinical review of medical claims and post-service appeals. You will analyze pre/post payments, perform audits, and apply CMS guidelines to determine medical necessity and appropriate care. Collaboration with Medical Director and other stakeholders is essential.

The role offers remote work, competitive hourly wages, and a comprehensive benefits package designed for experienced healthcare professionals dedicated to high-quality senior care.

Formación

• Associate's Degree or equivalent experience required.
• Current and active California RN License in good standing required.
• Bachelor's Degree or equivalent experience preferred.
• Certified Professional Coder preferred.
• 3-5 years of related experience in clinical decision making relative to Medicare patients.

Responsabilidades

• Provide clinical review of medical claims and post-service appeals.
• 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 and determine if medical records are needed.
• Apply CMS guidelines to complex, variable situations.
• Collaborate with Medical Director and other stakeholders on adjudication of claims and denials.

Conocimientos

Clinical decision making

Communication

Teamwork

Interpersonal skills

Educación

Associate's Degree or equivalent experience

Bachelor's Degree or equivalent experience preferred

Certified Professional Coder preferred

Descripción del empleo

SCAN Health Plan is hiring a registered nurse for clinical review of medical claims and post-service appeals. You will analyze pre/post payments, perform audits, and apply CMS guidelines to determine medical necessity and appropriate care. Collaboration with Medical Director and other stakeholders is essential.

The role offers remote work, competitive hourly wages, and a comprehensive benefits package designed for experienced healthcare professionals dedicated to high-quality senior care.