RN Nurse

Payrate : $56.15 - $60.00 / hr.

Responsibilities : Perform clinical claim reviews and first claim level determination approvals for members using FEP evidenced based guidelines, policies and nationally recognized clinal criteria

Conducts clinical review of claims for medical necessity, coding accuracy, medical policy compliance and contract compliance

Prepare and present cases to Medical Director (MD) for medical director oversight and medical necessity determination and communicate determinations to providers and / or members in compliance with federal and accreditation requirements

Develops and reviews member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards

Triages and prioritizes cases to meet required turn-around times

Identifies potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate

Provides referrals to Case Management, Disease Management, Appeals and Grievance and Quality Departments as necessary

Assists in the development and implementation of a proactive approach to improve and standardize overall retro claims review for clinical perspectives.

Other duties as assigned.

Required Skills : Requires a current CA RN License

Typically, requires a college degree or equivalent experience and prior relevant experience In Post Service / Claims Review, Prior Auth Experience or Outpatient Claims Experience

Knowledge of CPT, ICD-10, HCPCs and provider billing practices

Preferred Skills (nice to have) : Demonstrate the ability to act independently using sound clinical judgement

Able to handle multiple tasks simultaneously while prioritizing cases to meet regulatory and business based turnaround times

Demonstrated efficient, time management techniques and skills

Education Requirements :                Bachelor’s degree preferred

Software Skills Required :                Experience with MCG or Interqual Guidelines, preferred

Pay Transparency : The typical base pay for this role across the U.S. is : $56.15 - $60.00 / hr.   Final offer amounts, within the base pay set forth above, are determined by factors including your relevant skills, education and experience and the benefits package you select.  Full-time employees are eligible to select from different benefits packages.  Packages may include medical, dental, and vision benefits, 10 paid days off, 401(k) plan participation, commuter benefits and life and disability insurance.

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