Remote RN Claims Reviewer: Medical Appeals & Coding

Healing Strides Counseling; Wilkes-Barre (Luzerne County); Hybrid; USD 65,000 - 90,000; Full time

Job summary

Healing Strides Counseling seeks a qualified RN with coding expertise to review medical claims, evaluate records, and apply Medicare rules. The role involves regulatory interpretation and narrative decision writing, with attention to quality standards.

The position may require on-site attendance and occasional travel, supporting claims adjudication and training participation. A CPC/CCS certification is preferred, along with strong analytical and communication skills.

Qualifications

• Current, unrestricted RN license.
• 1+ year clinical experience.
• CPC or CCS certification preferred.
• Knowledge of Medicare regulations and guidelines.
• 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.

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 using policy and record documentation.
• Formulate a narrative decision citing regulatory documentation.
• Adjudicate claims based on regulations and records.
• Attend training sessions on site as needed.
• Complete IRR surveys as required by the prime contractor.
• Maintain a 97%+ quality score.

Skills

Analytical skills

Written communication

Verbal communication

Attention to detail

Team player

Education

Registered Nurse license

Tools

PC software

Job description

Healing Strides Counseling seeks a qualified RN with coding expertise to review medical claims, evaluate records, and apply Medicare rules. The role involves regulatory interpretation and narrative decision writing, with attention to quality standards.

The position may require on-site attendance and occasional travel, supporting claims adjudication and training participation. A CPC/CCS certification is preferred, along with strong analytical and communication skills.