CLINICAL CLAIMS REVIEWER

Location
Virginia Beach, VA
Posted
Aug 30, 2018
Closes
Oct 19, 2018
Function
Nurse
Industry
Healthcare, Other
Hours
Full Time
Job Description: 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

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

License
Required: Registered Nurse

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

Skills
Required: Coding, Service Orientation, Technology/Computer

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

Optima Health is hiring a Registered Nurse for the Clinical Claims Reviewer position in Virginia Beach, VA. This position is full time Monday- Friday 8am-5pm

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; and review of suspended claims for CPT, ICD, HCPCS coding, bundling issues and modifier utilization.

Coding knowledge/experience required.

Optima Health offers a full suite of commercial health insurance products including employee-owned and employer-sponsored plans, as well as Individual and Family health plans, employee assistance plans and plans serving Medicare and Medicaid enrollees. We offer programs to support members with chronic illnesses, customized wellness programs, and integrated clinical and behavioral health services.

As a nationally recognized provider of health plan coverage and innovative wellness programs, we live our mission “to improve health everyday.” This same commitment and dedication directs our philosophy as an employer. When you join Optima Health, you will experience our deep passion for heal and service excellence while benefiting from a culture of opportunity, learning, career growth, and support -every day. Optima Health is a service of Sentara Healthcare, so joining Optima is joining the Sentara Healthcare family.

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!


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.

Similar jobs

More searches like this