Medical Claims Reviewer

Active, unrestricted RN licensure from the United States and in the state of hire, or active compact multistate unrestricted RN license. Bachelor's degree in Nursing or graduate of an accredited School of Nursing. Five years clinical experience. Two years utilization/medical review, quality assurance, or home health experience. Working knowledge of managed care and healthcare delivery systems. Strong clinical experience (home health, rehabilitation, medical/surgical). Knowledge of specific criteria/protocol sets. 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. Ability to persuade, negotiate, or influence others. Analytical or critical thinking skills. Ability to handle confidential information with discretion. Proficient in Microsoft Office. Must have high-speed internet (non-satellite) and a private home office. Ability to travel to Augusta, GA office occasionally.

Performs medical claim reviews for medically complex services, preauthorization/predetermination requests, appeals, fraud referrals, and correct coding. Makes payment determinations based on clinical/medical information and established criteria. Determines medical necessity and appropriateness for coverage and reimbursement. Documents medical rationale to justify payment or denial. Educates internal/external staff on medical reviews, terminology, coverage, and coding. Participates in quality control activities. Provides guidance to LPN team members. Educates non-medical staff. Assists with special projects.