Karna, LLC

  • Claims Review Nurse

    Job ID 2018-1951
    Job Locations
    US-MD-Greenbelt
    Category
    Public Health
    Type
    Full-Time/Regular
  • Overview

    This position is for a medical claims review nurse on the World Trade Center (WTC) Health Program. The nurse will be responsible for reviewing claims that pend to Medical Review to ensure all services are medically necessary as well as analyzing and responding to provider appeals.

    Responsibilities

    • Medical claims review nurse (registered nurse) on the Medical Management team.
    • Responsible for completing medical claims review on a weekly basis, including:
      • Analyzing claims issues for claims pended to Medical Review
      • Performing evidence-based research
      • Determining whether claims issues can be resolved internally or require client review
      • Making recommendations to the client based on research and medical knowledge
      • Presenting findings to the client on a weekly basis
    • Reviews and responds to medical claims appeals.
    • Coordinates with the Clinical Centers of Excellence (CCEs) and Nationwide Provider Network (NPN) to obtain medical claims records and other needed documentation to resolve claims’ issues.
    • Researches medical code pricing using the FECA fee schedule and other pricing methodologies. Creates pricing rationales based on her research for client approval.
    • Conducts medical claims audits to ensure quality control.
    • Documents Medical Management processes, including medical claims review.
    • Completes ad hoc research for the client.

    Qualifications

    • BA/BS, preferably in a clinical discipline
    • Minimum five (5) years of relevant experience
    • Registered nurse (RN)
    • Experience with claims review, hospital experience preferred
    • Knowledge of Federal programs and payors, including the Centers for Medicare and Medicaid Services (CMS), the Office of Worker's Compensation Programs (OWCP) and Tricare, preferred.
    • Must be familiar with coding, including ICD-10, CPT and HCPCS
    • Current Certified Professional Coder license preferred
    • Experience with Quality Assurance review of medical claims and systems preferred
    • Experience in developing medical policies and procedures
    • Knowledge of workers' compensation claims is a plus
    • Good interpersonal and presentation skills for interacting with team members and clients
    • Good analytical and problem solving skills
    • Good organization skills to balance and prioritize work
    • Leadership skills to guide and mentor the work of less experienced personnel
    • Ability to keep sensitive and confidential material private
    • Well-versed in Microsoft Office products
    • Ability to obtain and maintain appropriate security clearance
    • Experience with SharePoint, Project and Visio preferred

     

     PM18

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