The Nurse Reviewer is primarily responsible for conducting post-service, pre or post payment in-depth claim reviews based on accepted medical guidelines and clinical criteria, billing and coding rules, plan policy exclusions, and payment errors/overpayments. Conduct review of facility and outpatient bills as it compares with medical records and coverage policies. Conduct prompt claim review to support internal inventory management to achieve greatest possible savings for clients.
Key responsibilities:
- RN or LPN required.
- Experience and working knowledge of Health Insurance, Medicare guidelines and various healthcare programs.
- Demonstrates expert understanding of audit techniques, identification of revenue opportunities and financial negotiation with providers.
- 3-5 years of auditing, claims, review and/or billing experience with a health care organization or provider preferred.
- 2+ years of auditing or performing claims review in specialty pharmacy claims or specialty drugs.
- Strong understanding and experience with utilizing Medicare and commercial drug reimbursement policies.
- Experience with working with clients and/or payors directly preferred.
- Experience with cross-functional work/collaboration for clinical projects.
- Proven ability to communicate regarding clinical assignments or projects as needed.
- Strong clinical assessment skills, analytical care planning and care management experience needed.
- Varied clinical experience, including Med/Surg, ICU or Emergency Medicine preferred.
- Excellent written and verbal communication skills.
- Highly organized with attention to detail.
- Payment Integrity, Coding and/or DRG experience preferred.
Job Requirements:
- Demonstrates solid understanding of audit techniques, identification of revenue opportunities and financial negotiation with providers.
- Proficiency in training techniques aimed at conveying subject matter expertise and scaling staff to maximize savings and revenue.
- Computer proficiency and technical aptitude with the ability to utilize CMS, EncoderPro, other audit software and tools, MS Office Suite.
- Thorough knowledge of company and departmental policies and procedures.
Independence/ Accountability:
- Maintain personal production and savings quota.
- Requires minimal daily supervision.
- Regularly reviews goals and objectives with supervisor.
- Oversees assigned projects/claims with the ability to manage requested escalation.
- Ability to follow detailed instructions on new assignments.
- Accountable for day-to-day tasks.
- Professional manner and respect the confidentiality of administrative matters and files.
- Ability to manage and prioritize multiple tasks.
- Ability to work under pressure and meet deadlines.
- Ability to withstand long periods of computer work.
Problem Solving:
- Makes logical suggestions as to likely causes of problems and independently recommends solutions.
- Excellent organizational skills are required to prioritize responsibilities, thus completing work in a timely fashion.
- Outstanding ability to multiplex tasks as required.
- Excellent project management skills.
- Attention to detail and concern for impact is essential.
- Excellent communication and presentation skills to effectively interface with the entire staff, and external representatives from the business, financial, legal and scientific communities.
Professional Experience:
- RN or LPN required.
- Coding and DRG experience preferred.
- Experience and working knowledge of Health Insurance, Medicare guidelines and various healthcare programs.
- Demonstrates strong understanding of audit techniques, identification of revenue opportunities and financial negotiation with providers.
- 3-5 years of auditing, claims, review and/or billing experience with a health care organization required.
- Understanding of hospital coding and billing rules.
- Demonstrates solid understanding of audit techniques.
- Excellent written and verbal communication skills.
- Highly organized with attention to detail.
- Clinical skills to evaluate appropriate Medical Record Coding and billing accuracy.
Leadership Activities:
- Regularly attends meetings and leads training sessions.
- Must be proactive to ensure proper follow up and completion of projects.
- Must maintain a professional demeanor in sensitive situations.
- Assists other departments as necessary.
Communication Skills:
- Must work well with others.
- Effectively communicate with others by giving and receiving feedback.
- Communicates ideas and information clearly.
- Must have excellent communication and presentation skills to effectively interface with the entire staff, and external representatives from the business, financial, legal and scientific communities.
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