Job title: Medical Claims Review Nurse – Full Remote
Company: Morgan Stephens
Job description: Position Title: Medical Claims Review Nurse
Type: Fully RemoteSchedule: Monday to Friday, 9:00 AM to 5:00 PM PST/PDT
Candidates must live in Pacific Time ZoneDaily Responsibilities:
- Reviewing medical patient records against standard medical criteria.
Minimum Qualifications:
- Three years of clinical appeals experience.
- One year of utilization review experience.
- Candidates with DRG experience on their resume will be prioritized for interviews.
Job Summary:
- Perform clinical/medical reviews of retrospective medical claim reviews, medical claims, and previously denied cases.
- Ensure medical necessity and appropriate/accurate billing and claims processing.
- Identify and report quality of care issues.
- Refer members with special needs to appropriate healthcare organization programs.
- Assist with complex claim review requiring decision-making based on clinical experience.
- Document clinical review summaries, bill audit findings, and audit details in the database.
- Provide supporting documentation for denial and modification of payment decisions.
- Re-evaluate medical claims independently by applying advanced clinical knowledge and relevant regulatory requirements.
- Review clinical guidelines with Medical Directors on denial decisions.
- Serve as a clinical resource for various stakeholders.
- Provide training, leadership, and mentoring.
- Resolve escalated complaints regarding utilization management and long-term services and supports.
- Prepare and present cases for various hearings as required.
Job Function:
- Administer claims payments, maintain claim records, and provide counsel to claimants.
- Monitor and control backlog and workflow of claims.
- Ensure timely settlement of claims in accordance with cost control standards.
Required Education:
- BSN Preferred.
Required Experience:
- Minimum three years of clinical appeals review experience.
- Minimum one year of utilization review.
Required License, Certification, Association:
- Active, unrestricted State Registered Nursing (RN) license in good standing.
- LPN/LVN Considered based on experience
Compensation and Benefits:
- $90,000 and up plus full benefit package
Expected salary: $90000 per year
Location: Seattle, WA
Job date: Wed, 24 Jul 2024 03:12:21 GMT
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