Nurse Reviewer RN /LPN

Work from home Full-time role Hiring

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), Licensed Practical Nurse (LPN), Registered Pharmacist, Occupational Therapist, Physical Therapist, Speech Therapist, or equivalent medical degree 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.

Remote but need to be local to 18702 RN preferred but LPN will be considered Apply To This Job