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 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.

physical requirements

• Must be able to remain in the stationary position 95% of the time
• Constantly operate a computer and other office equipment such as telephone
• Regular & predictable attendance is essential for this position