Advancing healthcare quality through innovation
Nurse Reviewer
Location
Virginia
Posted
8 hours ago
Salary
$45 - $55 / hour
Seniority
Senior
Job Description
Nurse Reviewer
LivantaLLC
• Conduct an initial assessment of documentation from both the initiating and responding parties. • Review submitted documentation to identify missing documents and determine what is required to resolve the dispute. • Follow procedures to obtain the appropriate documentation. • Determine the appropriate type of clinical reviewer necessary to complete the case, such as a medical coder or a physician. • Prepare documents for the arbitrator reviewer assigned and provide instructions as needed. • Collaborate with the legal team to facilitate resolution of disputes. • Draft professional determination correspondence. • Perform quality assurance checks on determinations according to Federal or State guidance. • Audit and analyze patient records to ensure appropriate determination. • Stay current with regulation changes and perform research on a case-by-case basis. • Deliver high-quality, professional determinations free of grammar and spelling errors. • Amend reports with additional clinical information when necessary. • Participate in an interdisciplinary health care team to achieve positive outcomes.
Job Requirements
- Maintain an active license in nursing ( at a minimum, RN required)
- Five years of full-time equivalent experience providing direct care to patients
- Hold a non-restricted nursing license in any state in the US.
- Ability to analyze clinical documentation and apply appropriate guidelines.
- Strong oral and written communication skills with excellent customer service.
- Ability to multitask and adapt to a fast-paced environment.
- Strong organizational skills and attention to detail
- Knowledge of claim review processes includes billing, Current Procedural Terminology (CPT) coding, and Explanation of Benefits.
- Familiarization with navigating electronic documents like PDFs, Microsoft Excel, Microsoft Word, and experience using Microsoft Outlook.
- Familiarization with electronic data repositories such as SharePoint and/or ShareFile.
- Exceptional skills in managing sensitive and confidential information.
- Strong organizational abilities, written, and verbal communication skills in English.
- Ability to work both independently and collaboratively with other team members to include clinical reviewers, physicians, and attorneys.
- Skilled in prioritizing tasks to align with business needs and assignments.
- Appeal and/or claim dispute-related experience.
- Medical Coding Certification preferred
- Experience with Utilization Review preferred
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