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Claims Review Nurse

Company: KARNA
Location: Greenbelt
Posted on: October 12, 2018

Job Description:

Claims Review Nurse 2US-MD-GreenbeltCategory Public HealthType Full-Time/Regular Overview This position is for a medical claims review nurse on the World Trade Center (WTC) Health Program. The nurse will be responsible for reviewing claims that pend to Medical Review to ensure all services are medically necessary as well as analyzing and responding to provider appeals. Responsibilities Medical claims review nurse (registered nurse) on the Medical Management team.Responsible for completing medical claims review on a weekly basis, including:Analyzing claims issues for claims pended to Medical ReviewPerforming evidence-based researchDetermining whether claims issues can be resolved internally or require client reviewMaking recommendations to the client based on research and medical knowledgePresenting findings to the client on a weekly basisReviews and responds to medical claims appeals.Coordinates with the Clinical Centers of Excellence (CCEs) and Nationwide Provider Network (NPN) to obtain medical claims records and other needed documentation to resolve claims' issues.Researches medical code pricing using the FECA fee schedule and other pricing methodologies. Creates pricing rationales based on her research for client approval.Conducts medical claims audits to ensure quality control.Documents Medical Management processes, including medical claims review.Completes ad hoc research for the client. Qualifications BA/BS, preferably in a clinical discipline Minimum five (5) years of relevant experienceRegistered nurse (RN)Experience with claims review, hospital experience preferredKnowledge of Federal programs and payors, including the Centers for Medicare and Medicaid Services (CMS), the Office of Worker's Compensation Programs (OWCP) and Tricare, preferred.Must be familiar with coding, including ICD-10, CPT and HCPCSCurrent Certified Professional Coder license preferredExperience with Quality Assurance review of medical claims and systems preferredExperience in developing medical policies and proceduresKnowledge of workers' compensation claims is a plusGood interpersonal and presentation skills for interacting with team members and clientsGood analytical and problem solving skillsGood organization skills to balance and prioritize workLeadership skills to guide and mentor the work of less experienced personnelAbility to keep sensitive and confidential material privateWell-versed in Microsoft Office productsAbility to obtain and maintain appropriate security clearanceExperience with SharePoint, Project and Visio preferred PM18

Keywords: KARNA, Baltimore , Claims Review Nurse, Healthcare , Greenbelt, Maryland

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