Medical Review Nurse - Onsite

Title: Medical Review Nurse - Onsite

Mandatory skills:

Medical nursing practice, medical case management protocols, quality management, utilization review protocols,
Maternal and Child Health services, preventive health, family planning, sterilization, pregnancy termination, EPSDT, acute, LTC, chronic long-term elderly, physical disabled, developmentally disabled, behavioral health, mental health, Tribal Healthcare delivery system nationally,
Managed care processes, nursing processes, assessment, planning, intervention, evaluation, managed care medical review,
InterQual Criteria, CCI, CPT, HCPCS, ICD-9, UR coding, retrospective review, CCI, lnterQual, HCPCS, revenue code,
Medical Claims Review, medical documentation, medical policies, claims policies,
Statistical analysis, Computer data retrieval, Computer data input,
UB claims, remote desktop access, claims industry standards

Description:

MEDICAL REVIEW NURSE - Claims Processor - RN license

The Role will be focused on the review and adjudication of the client 1500 claim forms. Some coordination will be required with medical providers for 2nd level reviews and evaluating against prior authorizations and UB claims.

Major duties and responsibilities include but are not limited to:
Performs medical claims review/adjudication using claims industry standards. Determines if a claim meets emergency criteria, medical necessity, and/or correct revenue code/CPT/HCPC coding. Also determines if the level of care and length of stay is appropriate for the client recipient.
Prepares reports and analyzes savings and trends. Interacts with other departments/providers as needed.
Performs special projects including but not limited to research projects.

Knowledge:
Medical nursing practice, medical case management protocols, quality management and utilization review protocols as related to all populations including Maternal and Child Health services, preventive health, family planning, sterilization, and pregnancy termination, EPSDT, acute, LTC, chronic long-term elderly and physical disabled, developmentally disabled, behavioral/mental health, and Tribal
Healthcare delivery system nationally and locally
Managed care processes
Acute nursing processes including assessment, planning, intervention, and evaluation
InterQual Criteria
CCI

Coding:
CPT, HCPCS, ICD-9
Medical Claims Review
Statistical analysis
Computer data retrieval and input
Interpretation of governmental client
Client Rules and Regulations
Code of Federal Regulations

Skills:
Organizational skills that result in prioritization of multiple tasks
Interpretation of rules, laws and client policy pertaining to the client program
Good written and communication skills
Computer skills
Utilization Review skills
Medical Claims Review skills
Producing work products with limited supervision
Effectively collaborating with people in positions of all levels
Research and analysis
Team player and can work independently

Abilities:
Interpret and apply medical and claims policies
Read and interpret medical documentation
Evaluate medical documentation for emergency criteria, medical necessity, correct CPT coding
Determine appropriate hospital levels of care and lengths of stay
Respond to inquiries for UR/CPT coding decisions
Maintain data for monthly reports
Work independently with minimal supervision
Ability to work Virtual Office

Experience Requirements:
High school Diploma
Minimum: Possession of a current license to practice as a registered nurse in AZ and experience in health care delivery systems.
Preferred: Experience in concurrent and retrospective review; CCI, lnterQual, HCPCS and CPT Coding; managed care medical review experience. Certification in CPT Coding is a plus.

Notes:
Primarily remote, however candidates may need to go onsite. Candidate may go onsite for training 1-2 times for training once starting position.
8:00am- 5:00pm 40hrs per week, (M-F, no weekends unless OT is requested).
Active RN License in AZ
The temp will need a computer which the client can set up remote desktop access.
The role does not currently allow for Overtime but could be approved as the client has need.

VIVA USA is an equal opportunity employer and is committed to maintaining a professional working environment that is free from discrimination and unlawful harassment. The Management, contractors, and staff of VIVA USA shall respect others without regard to race, sex, religion, age, color, creed, national or ethnic origin, physical, mental or sensory disability, marital status, sexual orientation, or status as a Vietnam-era, recently separated veteran, Active war time or campaign badge veteran, Armed forces service medal veteran, or disabled veteran. Please contact us at for any complaints, comments and suggestions.

Contact Details :

VIVA USA INC.
3601 Algonquin Road, Suite 425
Rolling Meadows, IL 60008