CLINICAL CLAIMS REVIEWER - Alabama Community Care Team

Virginia Beach, VA
Apr 26, 2017
Jul 25, 2017
Full Time
Job Description:
Optima Health is seeking a detail oriented Registered Nurse to serve as a Clinical Claims Reviewer for the Alabama Community Care division located in Virginia Beach, VA. This is a non-clinical role located in an office setting and requires daily coding, computing, and chart reviews and is a very rewarding opportunity for a nurse seeking to contribute in an efficient, analytical way.

Responsible for the coordination, investigation, documentation and resolution of provider inquiries and reconsiderations ensuring compliance with Optima Health policy and procedures and other regulatory agency standard guidelines; review of procedures for post-authorization based on medical necessity, medical and behavioral health standards of care, and benefit determinations; review of suspended claims for CPT, ICD, HCPCS coding, bundling issues and modifier utilization; will utilize knowledge of correct coding guidelines, CMS Correct Coding Initiative edits, Optima Health Coding policies, Milliman Criteria, Clinical Care Services Medical Policies and group benefits to determine appropriate claim approval/denials; will provide coding justifications for denials to providers; will identify trends in provider billing/coding errors and utilizes findings to create cost saving review opportunities.

Education Level
Bachelor's Level Degree - NURSING

Required: Acute Care - 3 years

Preferred: None, unless noted in the “Other” section below

Required: Registered Nurse

Preferred: None, unless noted in the “Other” section below

Required: Coding, Service Orientation, Technology/Computer

Preferred: None, unless noted in the “Other” section below

CPC within 1 year of eligibility. If RN candidate is not BSN prepared must be willing to sign an education agreement upon hire to complete BSN within 60 months of hire date, otherwise will not be considered.

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