Daily Responsibilities:

• Review medical patient records against standard medical criteria.
• Perform clinical/medical reviews of retrospective medical claim reviews, medical claims, and previously denied cases, where an appeal has been submitted.
• Identify and report quality of care issues.
• Assist with complex claim review requiring clinical decision-making experience.
• Document clinical review summaries, bill audit findings, and audit details in the database.
• Provide supporting documentation for denial and modification of payment decisions.
• Re-evaluate medical claims and associated records by applying advanced clinical knowledge, Federal and State regulatory requirements and guidelines, organizational policies and procedures, and individual judgment to assess the appropriateness of service provided, length of stay, and level of care.
• Review medically appropriate clinical guidelines and other criteria with Medical Directors on denial decisions.
• Supply criteria supporting all recommendations for denial or modification of payment decisions.
• Serve as a clinical resource for Utilization Management, Chief Medical Officers, Physicians, and Member/Provider Inquiries/Appeals.
• Provide training, leadership, and mentoring for less experienced clinical peers and LVN, RN, and administrative support staff.
• Resolve escalated complaints regarding Utilization Management and Long-Term Services & Supports issues.
• Prepare and present cases in conjunction with the Chief Medical Officers and Medical Directors for Administrative Law Judge pre-hearings, State Insurance Commission, and Meet and Confers.
• Represent and present cases effectively to Judicial Fair Hearing Officer during Fair Hearings as may be required.

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Job Function:

• Administer claims payments, maintain claim records, and provide counsel to claimants regarding coverage amount and benefit interpretation.
• Monitor and control backlog and workflow of claims.
• Ensure that claims are settled timely and in accordance with cost control standards.

Required Education:

• High School Diploma or GED

Required Experience:

• Minimum of three years of clinical appeals review experience.
• Minimum of one year of utilization review experience.
• DRG experience is prioritized.

Required License, Certification, Association:

• Active, unrestricted State Registered Nursing (RN) license in good standing.

Preferred License, Certification, Association:

• Certified Clinical Coder, Certified Medical Audit Specialist, Certified Case Manager, Certified Professional Healthcare Management, Certified Professional in Healthcare Quality, or other healthcare certification.

Medical Claim Review Nurse (Remote)