Claims Review Nurse
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Job Description
Claims Review Nurse resolving healthcare claim disputes for Capitol Bridge’s Florida and multi-state medical review programs. Assessing documentation, coordinating clinical reviewers, and drafting determinations.
Responsibilities:
- Conduct initial assessments of documentation from initiating and responding parties
- Review submissions, identify missing documents, and determine requirements for dispute resolution
- Obtain appropriate documentation according to established procedures
- Determine the appropriate clinical reviewer, such as a medical coder or physician
- Prepare case documents and provide instructions to assigned clinical reviewers
- Collaborate with the legal team to resolve disputes
- Draft professional determination letters
- Communicate with enrollees, health plans, and providers as needed
- Deliver determinations within required timelines
- Apply CPT code knowledge
- Participate in required meetings
- Collaborate with credentialed clinical professionals to determine medical necessity
- Use governmental and professional guidelines to assess appropriateness of services and procedures
- Adhere to company policies, state regulations, and project guidelines
- Complete reviews within assigned deadlines and follow QA/QC processes
- Uphold scheduling commitments and privacy regulations
- Perform other related duties as directed by leadership
Requirements:
- Maintain an active license in nursing
- Five years of full-time equivalent experience providing direct care to patients
- Hold a non-restricted nursing license in any state in the US
- Knowledge of claim review processes including billing, Current Procedural Terminology (CPT) coding, and Explanation of Benefits
- Familiarization with electronic documents such as PDFs, Microsoft Excel, Microsoft Word, and Microsoft Outlook
- Familiarization with electronic data repositories such as SharePoint and/or ShareFile
- Exceptional skills in managing sensitive and confidential information
- Strong organizational, written, and verbal communication skills in English
- Ability to work independently and collaboratively with clinical reviewers, physicians, and attorneys
- Skilled in prioritizing tasks according to business needs and assignments
- Appeal and/or claim dispute-related experience preferred
- Successful completion of a background check is required
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