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Nurse Reviewer RN /LPN

Location

United States

Posted

87 days ago

Salary

0

Seniority

Mid Level

No structured requirement data.

Job Description

Nurse Reviewer RN /LPN

Federal Hearings And Appeals

Role Description - Provide timely review and determination of medical claims, including prior authorization, appeals, and/or any other type 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. - 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. Qualifications - Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) certification through the American Academy of Professional Coders (AAPC) or AHIMA preferred. - Must possess a current, unrestricted State license as a Registered Nurse (RN), Licensed Practical Nurse (LPN), Registered Pharmacist, Occupational Therapist, Physical Therapist, Speech Therapist, or equivalent medical degree 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, policies, 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. 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 preferred but LPN will be considered.

Job Requirements

  • Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) certification through the American Academy of Professional Coders (AAPC) or AHIMA preferred.
  • Must possess a current, unrestricted State license as a Registered Nurse (RN), Licensed Practical Nurse (LPN), Registered Pharmacist, Occupational Therapist, Physical Therapist, Speech Therapist, or equivalent medical degree 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, policies, 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.
  • 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 preferred but LPN will be considered.

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