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...
- Rate: Not Specified
- Location: Bloomfield, US-CT
- Type: Permanent
- Industry: Finance
- Recruiter: Cigna
- Contact: Recruiter Name
- Email: to view click here
- Reference: 24012177
- Posted: 2024-09-28 08:45:45 -
- View all Jobs from Cigna
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