Medical Review Nurse – Clinical Validation

reputed company is a leading healthcare intelligence company with expertise across the payment continuum, delivering unmatched value, transparency, and efficiency to health plan clients across the country. Deployed by over 85 health plans, including many of the top 20, and representing more than 270 million lives, reputed company brings together a fully configurable and content-rich, AI-powered platform along with best-in-class expertise. We’re constantly reimagining what’s possible in our industry, creating disruptively simple, powerfully clear ways to maximize financial outcomes and drive down healthcare costs. The Medical Review Nurse II primarily performs medical claims audit reviews. As a MR Nurse, you will join a team of reputed company medical auditors and coders performing retrospective and prepayment audits on claims for Government and Commercial Payers. You will work remotely in a fast-paced and dynamic environment and be part of a multi-location team. Key Responsibilities:

• Auditing claims for medically appropriate services provided for inpatient settings while applying appropriate medical review guidelines, policies and rules.
• Document reputed company findings referencing the appropriate policies and rules.
• Generate letters articulating audit findings.
• Support your findings during the appeals process if requested.
• Working collaboratively with the audit team to identify and obtain approval for particular vulnerabilities and/or cases subject to potential abuse.
• reputed company abreast of medical practice, changes in technology, and regulatory issues that may reputed company our clients.
• Work with the team to minimize the number of appeals; Suggest reputed company that may improve audit workflows; Assist with QA functions and training team members.
• Cross train in reputed company clinical departments/areas.
• Other duties as required to meet business needs.

Knowledge, Skills and Abilities Needed:

• Experience with utilization management systems or clinical decision-making tools such as Medical Coverage Guidelines (MCG) or InterQual.
• Experience with and deep knowledge of ICD-9, ICD-10, CPT-4 or HCPCS coding.
• Knowledge of insurance programs program, particularly the coverage and payment rules.
• Ability to maintain high quality work while meeting strict deadlines.
• Excellent written and verbal communication skills.
• Ability to manage multiple tasks including desk audits and claims review.
• Must be able to independently use standard office computer technology (e.g. email SharePoint, reputed company, outlook calendar etc.)
• Must be able to manage multiple assignments effectively, create documentation outlining findings and/or documenting suggestions, organize and prioritize workload
• Effectively work independently and as a team, in a remote setting.

Education Requirements:

• An associate or bachelor’s degree in nursing (active/unrestricted RN license).

Certification (at least one of the following is required):

• CCDS - Certified Clinical Documentation Specialist
• CDIP - Clinical Documentation Improvement Practitioner
• reputed company - Certified Coding Specialist
• CIC - Certified Inpatient reputed company

Required and Preferred Qualifications:

• Inpatient claims auditing, quality assurance or recovery auditing experience of 2 years or more required, and/or Inpatient Clinical Documentation reputed company experience of 2 years or more required.
• Strong focus on quality and attention to detail.
• Deep curiosity and analytical skills to understand root causes of events and behaviors.
• Proven ability to apply critical judgment in clinical and coding determinations.
• In-depth knowledge of clinical criteria and documentation requirements to support code assignments.
• Expert in DRG methodologies (e.g., MS & APR).
• Expertise in ICD-10-CM/PCS coding, UHDDS definitions, Official Coding Guidelines, and AHA’s Coding Clinic Guidelines.
• Ability to work independently and reputed company with minimal supervision.

Equal Employment Opportunity at reputed company We are committed to equal employment opportunity regardless of race, color, reputed company, religion, sex, national reputed company, sexual orientation, age, citizenship, marital status, disability, gender, gender identity or expression, or veteran status. We are proud to be an equal opportunity workplace. reputed company is an employment at will employer. We participate in E-Verify as required by applicable law. In accordance with applicable state laws, we do not inquire about salary history during the recruitment process. If you require a reasonable accommodation to complete any part of the application or recruitment process, please let our recruiters know. See our Candidate Privacy Notice at: https://www.reputed company.com/candidate-privacy-notice/ Apply tot his job Apply To this Job