- Perform utilization management services within the scope of licensure
- Conduct comprehensive pre- and post-payment claim reviews
- Review inpatient, outpatient, concurrent, and retrospective authorization cases
- Address provider post-payment inquiries and reconsiderations
- Refer cases to Medical Directors as appropriate
- Ensure compliance with health plan policies and regulatory requirements, including BOI, NCQA, CMS, and Virginia DMAS
- Review member eligibility and benefits, medical policy, vendor guidelines, MCG, DMAS, and CMS criteria
- Provide written notification of review decisions to providers
- Facilitate accreditation by interpreting and applying accrediting and regulatory standards
- Review claim reconsiderations for accurate coding
- Evaluate code selection, modifiers, code bundling, unlisted codes, excessive procedures, diagnosis compatibility, frequency limits, and other coding edits
- Apply clinical knowledge and coding expertise to promote compliance, accuracy, and appropriate reimbursement
Requirements
- RN BSN required
- Bachelor's Degree in Nursing required
- Registered Nurse (RN) License (Compact or Virginia) required
- 3 years of acute care clinical experience required
- Medical Coding certification required within 1 year of hire
- Previous Utilization Review and Post Payment Review a plus
- MCG experience preferred
- Knowledge of NCQA preferred
- Strong verbal, written and interpersonal communication skills
- Problem solving skills
- Facilitation skills
- Analytic skills
- Certified Professional Coder (CPC) preferred
- Health Plan experience preferred
- Claims or post payment reconsideration experience preferred
- Standard working hours availability: 8am to 5pm EST, Monday-Friday
- Remote work available in Virginia, North Carolina, Alabama, Delaware, Florida, Georgia, Idaho, Indiana, Kansas, Louisiana, Maine, Maryland, Minnesota, Nebraska, Nevada, New Hampshire, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Washington, West Virginia, Wisconsin, or Wyoming
Core Competencies
Demonstrates expertise in Utilization Management and Medical Coding, ensuring compliance with health plan policies and regulatory standards. Proficient in conducting comprehensive claim reviews and applying clinical knowledge to promote accurate reimbursement.
Highest-signal resume keywords
- Utilization Management
- Medical Coding Certification
- Registered Nurse (RN) License
- Acute Care Clinical Experience
- NCQA Knowledge
Hard Skills
- Claim Review
- Coding Expertise
- Pre- and Post-Payment Review
- Diagnosis Compatibility Evaluation
- Coding Edits Application
Soft Skills
- Verbal Communication
- Written Communication
- Interpersonal Skills
- Problem Solving
- Facilitation Skills
Certifications & Qualifications
- RN BSN
- Medical Coding Certification
- Certified Professional Coder (CPC)
Industry Keywords
- Health Plan Compliance
- Accreditation Standards
- Claims Reconsideration
- Provider Inquiries
Tools & Technologies
- MCG
- CMS
- BOI
- Virginia DMAS
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Clinical Claims Reviewer, RN Arbeitgeber: Jobtailor
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