Registered Nurse (RN) Claims Reviewer

Location
Virginia Beach, VA
Posted
May 30, 2018
Closes
Jul 11, 2018
Function
Nurse
Industry
Healthcare, Other
Hours
Full Time
Job Description: Optima Health Community Care is hiring a Registered Nurse for the
Clinical Claims Reviewer position in Virginia Beach, VA.


Hours/Shift: Monday- Friday 8am-5pm

Department/Position Overview:

The selected candidate will be responsible for coordination, investigation, documentation and resolution of:

  • Provider inquiries and reconsiderations ensuring compliance with Optima Health policy, 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 benefits determinations
  • Review of suspended claims for CPT, ICD, HCPCS coding, bundling issues and modifier utilization.


Coding knowledge and adheres to correct coding guidelines as well as 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.

Facility Highlights:

Optima Health Community Care is a Commonwealth Coordinated Care Plus (CCC Plus) Medicaid plan for many older people and those with disabilities. CCC Plus is a Medicaid managed care program through the Virginia Department of Medical Assistance Services (DMAS).

With Optima Health Community Care, members benefit from an individualized, fully-integrated program with a state-wide network of providers. As an Optima Health Community employee, you will join a care team committed to providing customized and personalized support and services in the community that our members can count on. Optima Health is a service of Sentara Healthcare, so joining Optima is joining the Sentara Healthcare family.

Sentara Benefits:

Sentara employees strive to make our communities healthier places to live. We're setting the standard for medical excellence within a vibrant, creative, and highly productive workplace. For more information about our employee benefits, CLICK HERE!

Join our team, where we are committed to quality healthcare, improving health every day, and provide the opportunity for training, development, growth!

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

Experience
Required: Acute Care - 3 years

License
Required: Registered Nurse

Skills
Required: Coding, Service Orientation, Technology/Computer

Other
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.

Keyword: Registered Nurse, RN, Coding, Claims, ICD, CPT, HCPCS, investigations, CCC+

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