Medical Claims Review Nurse |
| Oct. 21, 2009 - Oct. 21, 2010 |
| Location: | St. Petersburg, FL |
| Exempt/Non-Exempt: | Exempt |
| Employment Type: | Full Time |
| Department: | Claims |
| Description: | The primary job of the Claims Review Nurse is to review and resolve the more complex professional and institutional claim issues to ensure that proper guidelines have been followed and that the claim was processed accurately. Responsible for analyzing, adjudicating and adjusting a variety of medical claims for payment. Assist with reviewing and analyzing high dollar adjustment claims. Also responsible for examining and evaluating claim submission patterns of health care providers to determine whether the patterns indicate the potential of health insurance fraud, abuse or waste.
This position requires a highest degree of compliance to HIPAA rules, as well as regulations from federal, state and local regulatory agencies.
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| Duties: | Review Medicare/Medicaid medical claims for coding accuracy and medical necessity for both professional and institutional claims
Conduct root cause analysis of claims issues. Have an understanding of the
regulations, provider contracts, and system configuration.
Act as a subject matter expect in claims processing and address questions from the team and other areas
Meet with other departments to discuss the resolution of claim issues
Work with the Director of Claims, Medical Director and Chief Medical Office, and consult policy files to verify information reported on a claim
Research and resolve inquiries involving fraud, abuse or waste received
Make a determination on the accuracy of provider billing patterns
Determine appropriate billing patterns or refer the claim to an investigator for a more thorough review
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| Qualifications: | RN Degree and two years of medical claims review or coding experience
Knowledge of professional and institutional claims processing and root cause analysis
Excellent written and verbal communication skills
Prefer certified coder but will consider nurse with claims experience
Understands Medicare Part A and B and Medicaid payment methodologies
Understanding of claims processing for institutional and professional claims
Knowledge to resolve claim issues and assist others with resolution of complex issues
Can effectively communicate with other areas in the organization and to providers regarding claim issues, root cause and resolution
Professional and Institutional claims review experience required
Analyze claims to determine if the claims processed correctly
General understanding of provider contracts
Knowledge of procedures used in fraud, abuse and waste detection and investigation
Understanding of data processing and fraud detection
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