RN, Post Service Clinical Review

Location: Remote

Duration: 3-4 months with possible extension

Description:

External Description & Internal Description:

Description – External

Federal Employee Program (FEP) Post Service Clinical Review RN – Ensures timely and accurate clinical claim review of designated healthcare services. Post Service Clinical Review RN preforms first level determination approvals for members using FEP and Client evidenced based guidelines, policies and nationally recognized clinical criteria across lines.

of business or for a specific line of business. Successful RN candidate review post service clinical claim review requests for benefits, medical necessity, coding accuracy and medical policy compliance. Clinical judgment and detailed knowledge of benefit plans used to complete review decisions is required.

Essential Responsibilities:

– Ensures proper procedure and diagnosis codes is reviewed for submitted procedures/claims.

– Solicits support from SME’s, leads and managers as appropriate

– Triages and prioritizes cases to meet required turn-around times

– Expedites access to appropriate care for members with urgent needs

– Prepares and submits clinical review cases to Medical Director (MD) for medical director oversight and necessity determination

– Communicate determinations to providers and/or members to in compliance with state, federal and accreditation requirements

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

– 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.

Job Requirements:

Qualifications – External& Internal:

– Current CA RN License.

– Bachelor of Science in Nursing or advanced degree preferred

– Requires practical knowledge of job area typically obtained through advanced education combined with experience.

– Typically, requires a college degree or equivalent experience and 3 years of prior relevant experience.

– Knowledge of CPT-4, ICD-10, HCPCs and provider billing practices

– Demonstrate the ability to act independently using sound clinical judgement

– Experience in a fast paced, production and quality environment preferred

– Demonstrated efficient, time management techniques and skills

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

Required Skills:

Excellent computer skills

Able to work through lots of information to obtain details.

Strong clinical vocabulary understanding

Able to work independently with minimal supervision.

Able to type/communicate clearly on determinations.

Nice to have:

Experience working claims reviews (either pre-auth, post auth review

Experience in Health Insurance industry

Fast Learner

Strong clinical experience

As an equal opportunity employer, ICONMA prides itself on creating an employment environment that supports and encourages the abilities of all persons regardless of race, color, gender, age, sexual orientation, citizenship, or disability.