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 but need to be local to 18702

RN required