Medical Claims Review Nurse
Position is fully remote
Schedule: M-F 9AM-5PM local time. The training schedule will be M-F 9AM-5PM EST.
Daily responsibilities: Candidates will be reviewing medical patient records against standard medical criteria.
Candidates MUST have 3 years of clinical appeals experience along with 1 year of utilization review experience. Candidates with DRG experience on the resume will be prioritized for interviews.

JOB SUMMARY:
• Performs clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases, in which an appeal has been submitted, to ensure medical necessity and appropriate/accurate billing and claims processing.
• Identifies and reports quality of care issues.
• Identifies and refers members with special needs to the appropriate healthcare organization program per
policy/protocol.
• Assists with Complex Claim review; requires decision making pertinent to clinical experience
• Documents clinical review summaries, bill audit findings and audit details in the database
• Provides supporting documentation for denial and modification of payment decisions
• Independently re-evaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of all relevant and applicable Federal and State regulatory requirements and guidelines, knowledge of healthcare organization policies and procedures, and individual judgment and experience to assess the appropriateness of service provided, length of stay and level of care.
• Reviews medically appropriate clinical guidelines and other appropriate criteria with Medical Directors on denial decisions.
• Supplies criteria supporting all recommendations for denial or modification of payment decisions.
• Serves as a clinical resource for Utilization Management, Chief Medical Officers, Physicians, and
Member/Provider Inquiries/Appeals.
• Provides training, leadership and mentoring for less experienced clinical peers and LVN, RN and
administrative support staff.
• Resolves escalated complaints regarding Utilization Management and Long Term Services & Supports
issues.
• Identifies and reports quality of care issues.
• Prepares and presents cases in conjunction with the Chief Medical Officers Medical Directors for
Administrative Law Judge pre-hearings, State Insurance Commission, and Meet and Confers.
• Represents the healthcare organization and presents cases effectively to Judicial Fair Hearing Officer during Fair Hearings as may be required.

JOB FUNCTION:
Responsible for administering claims payments, maintaining claim records, and providing counsel to claimants regarding coverage amount and benefit interpretation. Monitors and controls backlog and workflow of claims. Ensures that claims are settled in a timely fashion and in accordance with cost control standards.

REQUIRED EDUCATION:
Highschool Diploma or GED

REQUIRED EXPERIENCE:
Minimum three years clinical appeals review experience.
Minimum one year Utilization Review

REQUIRED LICENSE, CERTIFICATION, ASSOCIATION:
Active, unrestricted State Registered Nursing (RN) license in good standing.