Medical Claim Review Nurse

Job Title: Medical Claim Review Nurse

Location: 100% Remote

Duration: 3 to 6 Months+ (Opportunity for ext. / based off performance/evaluation and team needs/budget)

Schedule: 40hr- Must work PST hours. Once trained and working independently, select a shift between 6:00 am to 6:00 pm, Monday through Friday.

Job summary:

· Provides support for medical claim and internal appeals review activities - ensuring alignment with applicable state and federal regulatory requirements, Client policies and procedures, and medically appropriate clinical guidelines. Contributes to overarching strategy to provide quality and cost-effective member care.

Essential job duties:

· Facilitate clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases in which an appeal has been made, or is likely to be made, to ensure medical necessity and appropriate/accurate billing and claims processing.

· Reevaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of relevant and applicable state and federal regulatory requirements and guidelines, knowledge of Client policies and procedures, and individual judgment and experience to assess the appropriateness of services provided, length of stay, level of care, and inpatient readmissions.

· Validates member medical records and claims submitted/correct coding, to ensure appropriate reimbursement to providers.

· Resolves escalated complaints regarding utilization management and long-term services and support (LTSS) issues.

· Identifies and reports quality of care issues.

· Assists with complex claim review including diagnosis-related group (DRG) validation, itemized bill review, appropriate level of care, inpatient readmission, and any opportunities identified by the payment integrity analytical team; makes decisions and recommendations pertinent to clinical experience.

· Prepares and presents cases representing Client, along with the chief medical officer (CMO), for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings.

· Reviews medically appropriate clinical guidelines and other appropriate criteria with medical directors on denial decisions.

· Supplies criteria supporting all recommendations for denial or modification of payment decisions.

· Serves as a clinical resource for utilization management, CMOs, physicians and member/provider inquiries/appeals.

· Provides training and support for clinical peers.

· Identifies and refers members with special needs to the appropriate Client program by applicable policies/protocols.