Summary
 

Performs medical reviews using clinical/medical information provided by physicians/providers and established criteria/protocol sets or clinical guidelines. Documents decisions using indicated protocol sets or clinical guidelines. Provides support and review of medical claims and utilization practices.

Description
 

Logistics:

• Preferred candidate will live in Nashville, TN area. For those living in Nashville, the position would be hybrid (in-office and work from home).
• Highly qualified candidates outside the Nashville area will also be considered. For those living outside Nashville area, the position will be fully remote.
• To work from home, you must have high-speed (non-satellite) internet and a private home office.

What You’ll Do:

• 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/or abuse, correct coding for claims/operations. Makes reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines. Determines medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement. Monitors process’s timeliness in accordance with contractor standards. Documents medical rationale to justify payment or denial of services and/or supplies.
• Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.
• Participates in quality control activities in support of the corporate and team-based objectives. Provides guidance, direction, and input as needed to LPN team members. Provides education to non-medical staff through discussions, team meetings, classroom participation, and feedback. Assists with special projects and specialty duties/responsibilities as assigned by management.

To Qualify for This Position, You’ll Need:

• Required Licenses and Certificates: Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC).
• Required Education: Associate's in a job related field or Graduate of Accredited School of Nursing.
• Required Work Experience: Two years of clinical RN experience.
• Required Skills and Abilities: Working knowledge of word processing software. Ability to work independently, prioritize effectively, and make sound decisions. Good judgment skills. Demonstrated customer service and organizational skills. Demonstrated oral and written communication skills. Analytical or critical thinking skills. Ability to handle confidential or sensitive information with discretion.
• Required Software and Tools: Microsoft Office.

What We Prefer You Have:

• Work Experience: Five years of varied RN nursing experience to include:  Medical/Utilization Review, Emergency, Critical Care, Home Health, Long-term Care, Rehabilitation or Medical/Surgical experience, strongly preferred. Medicare or claims experience a plus.
• Software and Tools: Ability to use multiple Windows-based programs simultaneously.

What We Can Do for You

• 401(k) retirement savings plan with company match.
• Subsidized health plans and free vision coverage.
• Life insurance.
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