Medical Claims Review Nurse - Full Remote
Morgan Stephens
Long Beach, CA
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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
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