Post Service Clinical Review RN – Remote (California)

Post Service Clinical Review RN – Remote (California)
RN
6 Month Contract with potential to extend
8am-4pm


Day to Day Responsibilities of this Position and Description of Project:

Ensures accurate and timely clinical review of claims requiring review. The Post Service Clinical Review RN performs claim reviews utilizing company evidenced based guidelines, medical policies and nationally recognized clinical criteria. The successful RN candidate will review post service clinical claim review and provider appeals for medical necessity, coding accuracy and medical policy compliance. Clinical judgment and detailed knowledge of benefit plans used to complete review decisions is required.

The RN prepares and submits clinical case reviews to the Medical Director (MD) for MD collaboration and medical necessity determination, if needed
RN triages and prioritizes their caseload to meet required regulatory turn-around times
The RN communicates determinations to the members and providers in compliance with state, federal and accreditation requirements
The RN ensures the coding and diagnosis reviewed with the appeals submitted match the services being requested/billed for the member
The RN will refer members for Case Management as needs are identified
The RN will intervene appropriately if they identify potential quality of care issues and/or service or treatment delays

Required Skills (top 3 to 5/ non-negotiables):
1.Bachelor of Science in Nursing or advanced degree preferred and 3 years of prior relevant experience
2.Knowledge of CPT, ICD-10, HCPCS and billing practices
3.Demonstrate the ability to act independently using sound clinical judgement
4.Demonstrate strong verbal and communication skills
5.Proficient skills with Microsoft Office Suite

What you like to see on resumes? (nice to have)
1.Knowledge of Medical policy and benefit reviews
2.Ability to handle multiple tasks simultaneously
3.Experience in a fast paced, production and quality environment
4.Knowledge of regulations of DMHC and NCQA

Software Skills Required:
Microsoft Office

Required Certifications:
RN License