Medical Claims Review Nurse (RN)

AltaStaff is a staffing agency currently looking for a Medical Claims Review Nurse to work with our Managed Care Client!

Location: Remote (Candidates must reside in NY (outside greater NYC), FL, GA, MI, OH, WI, IA, NM, TX or KY)

Pay Rate: $41 - $43.00 hourly

Qualified candidates must have a valid RN License and have extensive claims/coding knowledge

DRG experience required!

Position Purpose: This position will be reviewing medical patient records against standard medical criteria. Responsible for administering claims payments, maintaining claim records, and providing counsel to claimants regarding coverage amount and benefit interpretation. Monitors and controls backlog and workflow of claims.

• Performs clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases, in which an appeal has been submitted, to ensure medical necessity and appropriate/accurate billing and claims processing.
• Identifies and reports quality of care issues.
• Identifies and refers members with special needs to the appropriate Healthcare program per policy/protocol.
• Assists with Complex Claim review; requires decision making pertinent to clinical experience
• Documents clinical review summaries, bill audit findings and audit details in the database
• Provides supporting documentation for denial and modification of payment decisions
• Independently re-evaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of all relevant and applicable Federal and State regulatory requirements and guidelines, knowledge of policies and procedures, and individual judgment and experience to assess the appropriateness of service provided, length of stay and level of care.

Education/Experience:

• Active, unrestricted State Registered Nursing (RN) license in good standing
• 3+ years of clinical appeals review experience required
• 2+ years of Utilization Review experience required
• DRG experience required
• Advanced coding certifications preferred
• Interpersonal, analytical, organizational and independent decision-making skills
• Clear and concise verbal and written communication skills

Work Environment Requirements:

• Must be able to to lift at least 30lbs
• Must be able to stand or sit for prolonged periods (75% of the time)
• Private Secured Internet Connection
• Must confirm work environment is safe and secure for work in handling private and sensitive information.
• Constantly operates a computer and other office equipment
• Constantly works indoors in a secluded safe space
• Must have High-speed internet access 25 MBPS minimum; 50 MBPS minimum preferred

Please note your resume will not be considered if you do not meet the listed requirements.

If you've applied and would like to view your application status, please visit:

AltaStaff is an Equal Employment Opportunity Employer. We provide equal employment opportunities to all qualified applicants for employment without regard to age, race, color, creed, religion, sex, marital status, national origin, ancestry, citizenship, disability, veteran status, sexual orientation, or any other protected status, in accordance with applicable federal, state, and local laws.

INDLP

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