Lpn Clinical Claims Reviewer (Hybrid/Remote Position)

Role:
The Clinical Claims Reviewer is responsible for the coordination, investigation, documentation and resolution of provider inquiries and reconsiderations ensuring compliance with payer policies and procedures and other regulatory agency standard guidelines. Handles review of procedures for pre/post-authorization based on medical necessity, medical and managed standards of care, and benefit determinations. Reviews denied claims for CPT, ICD, HCPCS coding, bundling issues and modifier utilization. Utilizes knowledge of correct coding guidelines, CMS Correct Coding Initiative edits, Health Coding policies, Clinical Care Services Medical Policies and group benefits to determine appropriate claim approval/denials. Provides justifications for denials to providers. Identifies trends in provider billing/coding errors and utilizes findings to create cost saving review opportunities

• Must be self-motivated and service oriented
• Minimum of two (2) years of hospice, palliative care, home health primary, and specialty care experience
• Excellent written and verbal communication skills
• Familiarity with CMS regulations and standards
• Familiarity with Medicare, Medicaid, commercial and CMS managed care initiatives
• Ability to work in a team environment.
• Current LPN licensure in the state of Florida, or current licensure from another state plus a temporary Florida permit
• Experience in Microsoft Outlook, Excel and Word
• Ability to prioritize and multi-task independently with little supervision or loss of focus

• Satisfactorily complete competency requirements for this position

• Improve own professional knowledge and skill level.
• Comply with all State, federal and local government regulations, maintaining a strong position against fraud and abuse.
• Use resources in a fiscally responsible manner.
• Observe the Company's health, safety, and security practices.
• Participate in Quality Assessment and Performance Improvement activities as appropriate for the position.
• Always represent the Company professionally through care delivered and/or services provided to all clients.
• Support Company research and educational activities.
• Participate proactively in improving performance at the organizational, departmental, and individual levels.
• Maintain the confidentiality of patients, families, colleagues, and other sensitive situations within the Company.
• Share expertise with co-workers both formally and informally.
• Comply with Company policies, procedures, and standard practices.
• Promote the Company through participation in community and professional organizations.
• Advance electronic media skills.

• Monitors processes’ timeliness in accordance with contractor standards.
• Performs first and second level of Medical Review in determination of claims payment review.
• Makes clinical judgment decisions based on clinical experience.
• Utilizes electronic health information imaging and inputs medical review decisions by electronic database module.
• Meets quality and production standards.
• Performs other duties as assigned.
• Provides education to non-medical staff through discussions, team meetings, classroom participation, and feedback.
• Makes reasonable charge payment determinations based on clinical medical information and established criteria, protocol sets, or clinical guidelines. Documents medical rationale to justify payment or denial of services and supplies. Determines medical necessity, appropriateness, reasonableness, and necessity for coverage and reimbursement.
• Promotes, acts, and collaborates as a unified team member to drive system alignments.
• Ensures departmental compliance with quality managements system and ISO requirements.
• Engages with staff and leadership in a manner that supports department’s mission, vision, and values.
• Records and reviews claims to make payment determinations based on Insurance coverage, coding, and utilization of services and practice guidelines for Medicare A and Physician Office and Professional Services, Ambulance Services, Laboratory, and other areas.
• Performs medical claim reviews for one or more of the following: claims for medically complex services, services that require preauthorization, predetermination, requests for appeal or reconsideration, referrals for potential fraud and abuse, and correct coding for claims and operations.
• Provides electronic documentation of findings and conclusions with determinations of claims payment appropriateness in review tool fields.
• Conducts in-depth claims analysis utilizing ICD-10-CM, CPT-4, and HCPCS Level II and CPT coding along with analysis and processing Medicare claims.