RN Claims Auditor & Medical Coding Specialist

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

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.