Utilization Claims Review Nurse
JOB
Summary: The Utilization Claims Review Nurse reviews and analyzes medical record and claims data, utilizing and applying Interqual Acute/Sub-acute Care Criteria and DRG coding practices to determine if inpatient admissions, observation stays, and ancillary services meet criteria. This position also maintains current information on regulatory guidelines as they pertain to acute and sub-acute levels of care.
Job Responsibility:
Review medical records and claims data for acute and sub-acute levels of care:
Review clinical information for accuracy
Review level of care and location of services delivered
Review itemized bill to ensure accurate billing
Complete review within established time frames
Update information in electronic claims system
Utilize clinical skills, chart review, physician communication, and Interqual standards for approval of claim
Initiate interdepartmental coordination to ensure quality and timely care for members
Review air, ambulance and ground transportation claims
Identify member's Third Party Liability coverage
Collect and screen data for clinical review:
Review claims with clinical reviewer when criteria is not met
Review clinical information and claims with Medical Director when clinical determination is necessary
Update authorizations as directed by the Medical Director
Provide assistance to Utilization Review Nurses:
Maintain information on members as required from hospitals
Distribute information to UR Nurses
Expected Outcomes:
Claim reviews are completed in a timely manner
Appropriate level of care is confirmed
Claims are paid within the identified time frame per contractual requirements
Interdepartmental communication occurs to request and obtain additional information to complete claim review
Members are identified with Third Party Liability coverage
Authorizations updated in timely manner
Members are in appropriate level of care according to criteria
Documentation is complete and accurate so claim is reimbursed in timely manner
Health Choice exists to improve the health and well-being of the individuals we serve through our health plans, integrated delivery systems and managed care solutions. We strive to recruit and retain only the finest health care professionals with the highest levels of integrity, compassion and competency. If you are driven by your own personal commitment to these values and desire to work in a team-focused, collaborative and supportive environment while still being valued for your individual strengths Health Choice is the place for you.
Equal Opportunity Employer Minorities/Women/Veterans/Disabled
Professional Competencies (knowledge, skills, and abilities):
Knowledge:
Knowledge of medical terminology
Medical Records and Coding
Interqual Acute/Sub-acute criteria
Knowledge of Medicare and Medicaid regulations and guidelines
Knowledge of ICD-9/ICD-10 (when applicable)
Knowledge of CPT and HCPCS codes
Skills:
Computer experience necessary
Effective time management skills
Effective interpersonal and communication skills
Abilities:
Ability to use electronic medical record and claims systems
Problem solving abilities
Work cooperatively, positively, and collaboratively in an interdisciplinary team
Work respectfully and positively with members
Ability to manage multiple tasks and prioritize work tasks to adhere to deadlines and identified time frames.
Education:
High School Diploma or equivalent GED
Associates degree or Bachelor's degree from an accredited Nursing School preferred
Experience:
At least one (1) year medical claims experience
At least one (1) year experience working in a medical environment, such as a hospital, medical office, health plan
Previous Medicaid/Medicare experience preferred
Certification and License:
Active, current, valid, unrestricted Arizona State Registered Nurse (RN) License or LPN
. Apply now!Estimated Salary: $20 to $28 per hour based on qualifications.
Summary: The Utilization Claims Review Nurse reviews and analyzes medical record and claims data, utilizing and applying Interqual Acute/Sub-acute Care Criteria and DRG coding practices to determine if inpatient admissions, observation stays, and ancillary services meet criteria. This position also maintains current information on regulatory guidelines as they pertain to acute and sub-acute levels of care.
Job Responsibility:
Review medical records and claims data for acute and sub-acute levels of care:
Review clinical information for accuracy
Review level of care and location of services delivered
Review itemized bill to ensure accurate billing
Complete review within established time frames
Update information in electronic claims system
Utilize clinical skills, chart review, physician communication, and Interqual standards for approval of claim
Initiate interdepartmental coordination to ensure quality and timely care for members
Review air, ambulance and ground transportation claims
Identify member's Third Party Liability coverage
Collect and screen data for clinical review:
Review claims with clinical reviewer when criteria is not met
Review clinical information and claims with Medical Director when clinical determination is necessary
Update authorizations as directed by the Medical Director
Provide assistance to Utilization Review Nurses:
Maintain information on members as required from hospitals
Distribute information to UR Nurses
Expected Outcomes:
Claim reviews are completed in a timely manner
Appropriate level of care is confirmed
Claims are paid within the identified time frame per contractual requirements
Interdepartmental communication occurs to request and obtain additional information to complete claim review
Members are identified with Third Party Liability coverage
Authorizations updated in timely manner
Members are in appropriate level of care according to criteria
Documentation is complete and accurate so claim is reimbursed in timely manner
Health Choice exists to improve the health and well-being of the individuals we serve through our health plans, integrated delivery systems and managed care solutions. We strive to recruit and retain only the finest health care professionals with the highest levels of integrity, compassion and competency. If you are driven by your own personal commitment to these values and desire to work in a team-focused, collaborative and supportive environment while still being valued for your individual strengths Health Choice is the place for you.
Equal Opportunity Employer Minorities/Women/Veterans/Disabled
Professional Competencies (knowledge, skills, and abilities):
Knowledge:
Knowledge of medical terminology
Medical Records and Coding
Interqual Acute/Sub-acute criteria
Knowledge of Medicare and Medicaid regulations and guidelines
Knowledge of ICD-9/ICD-10 (when applicable)
Knowledge of CPT and HCPCS codes
Skills:
Computer experience necessary
Effective time management skills
Effective interpersonal and communication skills
Abilities:
Ability to use electronic medical record and claims systems
Problem solving abilities
Work cooperatively, positively, and collaboratively in an interdisciplinary team
Work respectfully and positively with members
Ability to manage multiple tasks and prioritize work tasks to adhere to deadlines and identified time frames.
Education:
High School Diploma or equivalent GED
Associates degree or Bachelor's degree from an accredited Nursing School preferred
Experience:
At least one (1) year medical claims experience
At least one (1) year experience working in a medical environment, such as a hospital, medical office, health plan
Previous Medicaid/Medicare experience preferred
Certification and License:
Active, current, valid, unrestricted Arizona State Registered Nurse (RN) License or LPN
. Apply now!Estimated Salary: $20 to $28 per hour based on qualifications.
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