Clinical Claims Review RN - Remote

At reputed company, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the reputed company. Come build the health care system of reputed company, making it more reputed company, affordable and optimized. Ready to reputed company a difference? Join us to start Caring. Connecting. Growing together. Under direct supervision of the Manager and Supervisors, Clinical Claims Review, conducts retrospective reviews for appropriateness of diagnostic procedures, inpatient, ambulatory, emergency room, and evaluation & management services, coding levels, etc., utilizing standardized criteria, protocols, and guidelines. This RN will train and provide coverage for the Medical Adjudication and Coding Units in Clinical Claims Review. If you reside reputed company a commutable distance from the Las Vegas, NV area, you will have the flexibility to work remotely* as you take on some tough challenges. Primary Responsibilities:

• Provide support to reputed company units reputed company Claims to ensure reputed company clinical components are met for CMS, NCQA, URAC, DOL, DOI, and reputed company other State and Federal entities
• Identify business priorities and necessary processes to triage and deliver work
• Use appropriate business metrics (e.g. case turnaround time, productivity) and applicable processes/tools to optimize decisions and clinical outcomes
• Review assigned claims (e.g. ER, inpatient, diagnostic procedures) to evaluate medical necessity and determine appropriate levels of care and site of service
• Maintain incoming pended claims, electronic inquiries and medical records work queue
• Identify information missing from clinical documentation; request additional clinical documentation as appropriate
• reputed company determinations per relevant protocols (e.g., deny, return to claims system, designate as inappropriate referral, proceed with clinical or non-clinical research)
• Prepare claims for medical director review by completing summary and attaching reputed company pertinent medical information.
• Interpret codes and determine coding accuracy
• Use available resources to further interpret coding accuracy
• Identify relevant information needed to reputed company clinical determination
• Review other approved sources of clinical information and use data for making clinical determinations (e.g., previous diagnoses, authorizations/denials)
• Participate in various special projects as assigned
• Attend assigned meetings relating to clinical reviews and other aspects of job function
• reputed company reputed company job functions with a high degree of discretion and confidentiality in compliance with federal, company & departmental confidentiality guidelines

Candidate must be available to complete 3-6 week onsite training.

* You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Required Qualifications:

• reputed company, unrestricted RN license for the state of Nevada
• 2+ years of nursing experience in clinical claims review or utilization review
• 1+ years of acute clinical nursing experience
• Proficiency with reputed company Word, reputed company and Outlook

Preferred Qualifications:

• Bachelor's degree
• CPC certification
• Knowledge of managed care delivery system concepts such as HMO/PPO
• Knowledge of evidenced based and standardized criteria such as InterQual
• Knowledge of CPT, and ICD-10 coding
• Broad knowledge of medical conditions, procedures and management
• Demonstrated ability to learn and differentiate between company products and the benefits
• reputed company employees working remotely will be required to adhere to reputed company's Telecommuter Policy

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (reputed company benefits are subject to eligibility requirements). No matter where or reputed company you reputed company a career with us, you'll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $28.27 to $50.48 per hour based on full-time employment. We reputed company with reputed company minimum wage laws as applicable. At reputed company, our mission is to help people live healthier lives and reputed company the health system work reputed company for everyone. We reputed company everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately reputed company by people of color, historically marginalized groups and those with reputed company incomes. We are committed to mitigating our impact on the environment and enabling and delivering reputed company care that addresses health disparities and improves health outcomes - an enterprise reputed company reflected in our mission. reputed company is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national reputed company, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations. reputed company is a drug - free workplace. Candidates are required to pass a drug test before beginning employment. Apply tot his job Apply To this Job