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Job Description
Position Purpose:
Under the supervision of the Manager of Health Services, the Claims Review Nurse performs clinical review as it pertains to reimbursement function and the appeals and grievance process. Medical necessity evaluations are made based on nationally recognized criteria for all prior authorizations, admissions and concurrent reviews and in coordination with the health plan Medical Director or Chief Medical Officer.
This position is responsible for maintaining relationships and performing functions with/for Reimbursement Services, claim check processes, Customer Service, provider/member reconsiderations and coordinates with other Health Services team members to ensure the members experience exceeds expectations.
Nature and Scope:
This position is responsible for broad interaction with Health Services, Customer Service, Reimbursement Services and the clinical aspects of claims processing, medical record review and medical research. This position has frequent interaction with the Medical Director as it relates to code and criteria research, summarization of reconsiderations, grievances and the pre-certification process.
The Claims Review nurse collaborates to promote positive outcomes, quality) and the utilization of patient/member care resources in an efficient and cost-effective manner within the benefit plan structure.
The scope includes cross training within the continuum of all care coordination roles to cover for departmental vacations, illness, vacancies and shortages.
Knowledge, Skills & Abilities
Excellent written and verbal communication skills
Ability to translate medical data for effective education and communication
Knowledge of research basics and the ability to format claims and appeals information into a document for MD review
Ability to assess a situation, consider alternatives and take appropriate actions
Ability to manage change
Excellent organizational and time management skills
Applies medical necessity guidelines to complete utilization review procedures to ensure the member is
receiving quality cost effective care in the appropriate setting
Knowledge of continuous quality improvement process
Knowledge of applicable regulatory requirements and community resources
Documents all medical necessity determinations and member contacts in utilization review system
This position does not provide patient care.
The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.
Minimum Qualifications: Requirements – Required and/or Preferred
Education:
Must have working-level knowledge of the English language, including reading, writing and speaking English. Appropriate education to obtain and maintain Registered Nurse licensure in the State of Nevada.
Experience:
Applicant with previous managed care or case management experience preferred with experience in working with coding (CPT, ICD-9/ICD-10, HCPCS, and DRG) and Customer Service.
License(s):
Current and unrestricted State of Nevada Registered Nurse license.
Certification(s):
Case Management; Professional Utilization Review or Managed Care Certification
recommended.
Computer / Typing:
Must be proficient with Microsoft Office Suite, including Outlook, PowerPoint, Excel and
Word and have the ability to use the computer to complete online learning requirements for
job-specific competencies, access online forms and policies, complete online benefits
enrollment, etc.
