Medical Claims Review Nurse Jobs

Onsite, Remote or Remote Location Specific :: Onsite

Free Training to upgrade your skills

Payrate or Pay range :: $43/hr on w2

Contract or Permanent :: Contract

Weekly pay with direct deposit

Dedicated Career Partner to help you achieve your career goals

Engage clients in appropriate communication that manages client expectations and builds a collaborative relationship with the client

Make clinical judgments based on clinical experience when applicable

Understand and represent PRI?s mission, vision, and values to all internal and external customers

Perform medical record and claims review in accordance with all State and Federal mandated regulations

Maintain compliance with all regulation changes as they impact medical and utilization review practices

Analyze patient records and participate in interdisciplinary collaboration with PRI staff and all recognized teaming partners and/or subcontractors

Years of experience in supporting, administering, managing content management platform such as Sharepoint

years of experience in supporting, administering, managing content management platform such as Sharepoint

Maximize family time with no weekend, Holiday, or on-call requirements

Take advantage of our competitive, comprehensive benefits package including medical, dental, vision, life, short-term disability, long-term disability & 401(k)

Ensure that all documentation includes a valid signature consistent with the signature requirements

Complete one-on-one provider education (i.e., webinar, conference call, etc.) within 30 days of sending out review results letter

Engage clients in appropriate communication that manages client expectations and builds a collaborative relationship with the client

Make clinical judgments based on clinical experience when applicable

Understand and represent PRI’s mission, vision, and values to all internal and external customers

Perform medical record and claims review in accordance with all State and Federal mandated regulations

Maintain compliance with all regulation changes as they impact medical and utilization review practices

Analyze patient records and participate in interdisciplinary collaboration with PRI staff and all recognized teaming partners and/or subcontractors

Engage clients in appropriate communication that manages client expectations and builds a collaborative relationship with the client

Make clinical judgments based on clinical experience when applicable

Understand and represent PRI?s mission, vision, and values to all internal and external customers

Perform medical record and claims review in accordance with all State and Federal mandated regulations

Maintain compliance with all regulation changes as they impact medical and utilization review practices

Analyze patient records and participate in interdisciplinary collaboration with PRI staff and all recognized teaming partners and/or subcontractors

Experience with utilization management systems or clinical decision making tools such as MCG or InterQual.

Other duties, responsibilities, and qualifications may be required and/or assigned as necessary

Typing skills and working knowledge of computer functions and applications such as MS office (Outlook, Word, Excel).

Works collaboratively with the audit team to identify vulnerabilities and/or cases subject to potential Fraud Waste and Abuse (FWA).

Maintain a current knowledge of Medicare and Commercial regulations, policies and procedures

Maintain coding certification to ensure eligibility to perform audits on behalf of Performant

Experience with utilization management systems or clinical decision making tools such as Medical Coverage Guidelines (MCG) or InterQual.

Working collaboratively with the audit team to identify and obtain approval for particular vulnerabilities and/or cases subject to potential abuse

Work in partnership with our clients, CMD colleagues, and other contractors on improving medical policies, provider education, and system edits

Strong preference for experience performing utilization review for an insurance company, Tricare, MAC or organizations performing similar functions

Experience with ICD-9, ICD-10, CPT-4 or HCPCS coding.

Knowledge of insurance programs program, particularly the coverage and payment rules.

Retrospective utilization management case review

Knowledge, Experience, and Key Attributes needed for Success:

2+ years of clinical nursing experience

Knowledge of Utilization Review processes

Knowledge of the medical plan appeal process (preferred)

Strong experience in clinical practice with diverse diagnoses