Medical Claims Review Nurse - Full Remote
Morgan Stephens
Long Beach, CA
Be among the first 25 applicants
See who Morgan Stephens has hired for this role
Position Title: Medical Claims Review Nurse
Type: Fully Remote
Schedule: Monday to Friday, 9:00 AM to 5:00 PM PST/PDT
Candidates must live in Pacific Time Zone
Daily Responsibilities
Type: Fully Remote
Schedule: Monday to Friday, 9:00 AM to 5:00 PM PST/PDT
Candidates must live in Pacific Time Zone
Daily Responsibilities
- Reviewing medical patient records against standard medical criteria.
- Three years of clinical appeals experience.
- One year of utilization review experience.
- Candidates with DRG experience on their resume will be prioritized for interviews.
- 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.
- 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.
- BSN Preferred.
- Minimum three years of clinical appeals review experience.
- Minimum one year of utilization review.
- Active, unrestricted State Registered Nursing (RN) license in good standing.
- LPN/LVN Considered based on experience
- $90,000 and up plus full benefit package
-
Seniority level
Mid-Senior level -
Employment type
Full-time -
Job function
Health Care Provider -
Industries
Staffing and Recruiting
Referrals increase your chances of interviewing at Morgan Stephens by 2x
See who you knowGet notified about new Medical Specialist jobs in Long Beach, CA.
Sign in to create job alertSimilar jobs
People also viewed
-
Registered Nurse (RN)
Registered Nurse (RN)
-
Registered Nurse (RN)
Registered Nurse (RN)
-
Registered Nurse (RN)
Registered Nurse (RN)
-
Registered Nurse - Residential
Registered Nurse - Residential
-
AK - Nurse Manager, Phone Triage
AK - Nurse Manager, Phone Triage
-
REGISTERED NURSE-ADULT ACUTE CARE
REGISTERED NURSE-ADULT ACUTE CARE
-
Travel Nurse RN - Case Manager - $2,534 per week in Sunnyvale, CA
Travel Nurse RN - Case Manager - $2,534 per week in Sunnyvale, CA
-
Travel Nurse RN - Med/Surg - $2,073 per week in Canton, OH
Travel Nurse RN - Med/Surg - $2,073 per week in Canton, OH
-
Registered Nurse/Night (3x12 Hours) 19:00 7:30
Registered Nurse/Night (3x12 Hours) 19:00 7:30
-
Registered Nurse/Night (3x12 Hours) 19:00 7:30
Registered Nurse/Night (3x12 Hours) 19:00 7:30
Looking for a job?
Visit the Career Advice Hub to see tips on interviewing and resume writing.
View Career Advice Hub