Nurse Reviewer RN

Provide timely review and determination of medical claims, including prior authorization, appeals, and/or any other type of medical claims; Provide timely review and determination of medical claims; Analyze medical records related to the case file; Review and interpret Local Coverage Determination (LCD), National Coverage Determination (NCD) policies, and other federal regulations; Apply appropriate regulatory citations, including health plan policies, NCD/LCDs, and/or other regulations to each claim as it relates to the item or issue; Formulate a narrative decision citing relevant regulatory back-up documentation contained within the medical record; Adjudicate claim based on the regulations and documentation contained within the medical record; Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) certification through the American Academy of Professional Coders (AAPC) or AHIMA preferred; Maintain professional licensure in active and unrestricted status as required by state of issuance; Attend FHAS and/or client Lunch & Learn sessions and/or general training sessions on site as needed. Complete IRR surveys in a timely fashion as required by the prime contractor Maintain a 97% or higher quality score work experience requirements Must possess a current, unrestricted State license as a Registered Nurse (RN),as required by contract(s). 1+ years clinical experience required; coding, utilization, and/or medical chart review preferred. Professional Coding Certification preferred. Detailed knowledge of Medicare regulations and guidelines, polices, and payor reimbursements preferred. Knowledge of CPT, HCPCS, ICD-10 codes and coding guidelines. Ability to identify Medicare billing and payment irregularities. Must be able to support review findings by utilizing exceptional analytical, written and oral communication skills. Ethical, self-motivated and results oriented team player. Strong analytical, verbal and written communication skills. Outstanding people skills and ability to effectively review findings /results with management. Must be proficient with PC and related software programs. Excellent organizational skills. Must be a team player. Limited travel may be required. physical requirements Must be able to remain in the stationary position 95% of the time Constantly operate a computer and other office equipment such as telephone Regular & predictable attendance is essential for this position Remote #J-18808-Ljbffr