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Nurse Reviewer RN in Wilkes-Barre, Pennsylvania at Federal Hearings And Appeals

NewSalary: $67500 - $95000Job Function: Medical
Federal Hearings And Appeals
Wilkes-Barre, Pennsylvania, 18702, United States
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Job Description

  • Provide timely review and determination of medical claims, including prior authorization, appeals, and/or any other type of medical claims;
  • Provide timely review and determination 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;
  • Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) certification through the American Academy of Professional Coders (AAPC) or AHIMA preferred;
  • Maintain professional licensure in active and unrestricted status as required by state of issuance;
  • 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
work experience requirements
  • Must possess a current, unrestricted State license as a Registered Nurse (RN),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, polices, 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.
physical 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 required

Job Location

Wilkes-Barre, Pennsylvania, 18702, United States

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