Clinical Review Nurse

Health Insurance Waste Investigator

This role investigates Health Insurance Waste and Error stopped claims by gathering information, researching state and federal guidelines, and following internal procedure to determine the viability of the claim for further review in a production environment. You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Key Responsibilities:

• Clinical Case Reviews - 75%
  • Perform clinical review of professional (or facility) claims vs. medical records to determine if the claim is supported or unsupported
  • Maintain standards for productivity and accuracy. Standards are defined by the department
  • Provide clear and concise clinical logic to the providers when necessary
  • Examine, assess, and document business operations and procedures to ensure data integrity, data security and process optimization
  • Investigate, recover, and resolve all types of claims as well as recovery and resolution for health plans, commercial customers, and government entities
  • Investigate and pursue recoveries
  • Ensure adherence to state and federal compliance policies, reimbursement policies, and contract compliance
  • Use pertinent data and facts to identify and solve a range of problems within area of expertise
  • Other internal customer correspondence and team needs - 15%
  • Attend and provide feedback during monthly meetings with assigned internal customer department
  • Provide continuous feedback on how to improve the department relationships with internal team members and departments
• Continuing education - 10%
  • Keep up required Coding Certificate and/or Nursing Licensure
  • Complete compliance hours as required by the department

Requirements:

• At least ONE of these certifications/licensures:
  • Puerto Rico Registered Nurse
  • Certified Professional Coder (CPC) + CPC A
  • Certified Inpatient Coder (CIC)
  • Certified Outpatient Auditor (COC)
  • Certified Professional Medical Auditor (CPMA)
  • Certified Coding Specialist (CCS)
• Demonstrated proficiency with computers, including Microsoft Suite of products
• Ability to work on-site at San Juan, PR. Work model could change to hybrid or remote after the 8-week training.
• Willing or able to work from Monday to Friday, 40 hours per week during our business operating hours of 8am - 7pm ATL
• Professional proficiency in both English and Spanish (Please note that an English proficiency assessment will be required for this position)

Salary: $21 per hour, full time job

Required availability: Monday to Friday between 8:00am - 7:00pm