Nurse Reviewer RN /LPN

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 contractorMaintain a 97% or higher quality scorework experience requirementsMust 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. physical requirementsMust be able to remain in the stationary position 95% of the timeConstantly operate a computer and other office equipment such as telephoneRegular & predictable attendance is essential for this position
Remote but need to be local to 18702RN preferred but LPN will be considered

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