RN Medicare Advantage Dispute Nurse, Work from Home, Anywhere USA

Major Job Responsibilities


* Responsible for leveraging clinical and/or coding experience and perform facility and provider medical record reviews in support the development of a dispute decision as it relates to Payment Integrity Program Claim disputes (i.e.

Claims XTEN, Prepay Vendors, etc.).


* Utilize clinical data and/or coding guidelines, medical information, benefit plan, coverage policies, LCDs and NCDs to support defensible and accurate dispute decisions.


* Initiate referrals and interact with Medical Directors.


* Function independently in a fast paced and continuously evolving department.


* Collaborate with matrixed partners such as Physicians, Operations, Vendors, etc.


* Adheres to production and quality metric goals.


* Support for client facing teams as needed relating to client inquiries related to provider disputes.


* Communicate and partner with Operations teams regarding important issues and trends.


* Manages escalated cases expediently.


* Secures supervisory assistance with problem solving and decision making as needed.


* Utilizes effective communication, courtesy, and professionalism in all interactions, both internally and externally.


* Identify and refer cases for possible fraud to the appropriate matrix partners.


* Participates in special projects as needed.


* Performs additional duties as assigned.

Requirements


* Bachelor's or associate Degree or Nursing Diploma.


* Current RN licensure (unrestricted) in state where reside.

Must maintain active nursing license as required by state and company guidelines.


* Clinical experience in acute setting for 2 or more years.


* Experience with Medicare Advantage clinical reviews for claims, disputes or appeals.


* Experience with Diagnosis Related Grouping (DRG), LCDs and NCDs, Medically Unlikely Edits (MUE), Medical Necessity and Readmissions.


* This position requires at least one year experience in coding knowledge and industry expertise to ensure adherence to proper coding and billing guidelines [i.e.

International Classification of Diseases, Ninth and Tenth Revisions, Clinical Modification and Procedure Coding System (ICD-9 and 10, CM and PCS) American Medical Association Current Procedural Terminology (CPT) Coding system, and Healthcare Common Procedure Coding System (HCPCS) codes].

Preferred Requirements


* Recent Utilization Review or Claims Review experience.


* Knowledge of the Insurance Industry.


* Knowledge of NCQA and URAC Guidelines.


* Certified Coder.

If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.

For this position, we anticipate offering an annual salary of 62,900 - 104,800 USD / yearly, depending on relevant factors, including experience and geographic location.

This role is also...