- Provide timely review and determination of medical claims, including prior authorization, appeals, and/or any other type of medical claims;
- Provide timely review and determination of medical claims;
- Analyze medical records related to the case file;
- Review and interpret Local Coverage Determination (LCD), National Coverage Determination (NCD) policies, and other federal regulations;
- Apply appropriate regulatory citations, including health plan policies, NCD/LCDs, and/or other regulations to each claim as it relates to the item or issue;
- Formulate a narrative decision citing relevant regulatory back-up documentation contained within the medical record;
- Adjudicate claim based on the regulations and documentation contained within the medical record;
- Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) certification through the American Academy of Professional Coders (AAPC) or AHIMA preferred;
- Maintain professional licensure in active and unrestricted status as required by state of issuance;
- Attend FHAS and/or client Lunch & Learn sessions and/or general training sessions on site as needed.
- Complete IRR surveys in a timely fashion as required by the prime contractor
- Maintain a 97% or higher quality score
work experience requirements
- Must possess a current, unrestricted State license as a Registered Nurse (RN), Licensed Practical Nurse (LPN), Registered Pharmacist, Occupational Therapist, Physical Therapist, Speech Therapist, or equivalent medical degree as required by contract(s).
- 1+ years clinical experience required; coding, utilization, and/or medical chart review preferred.
- Professional Coding Certification preferred.
- Detailed knowledge of Medicare regulations and guidelines, polices, and payor reimbursements preferred.
- Knowledge of CPT, HCPCS, ICD-10 codes and coding guidelines.
- Ability to identify Medicare billing and payment irregularities.
- Must be able to support review findings by utilizing exceptional analytical, written and oral communication skills.
- Ethical, self-motivated and results oriented team player.
- Strong analytical, verbal and written communication skills.
- Outstanding people skills and ability to effectively review findings /results with management.
- Must be proficient with PC and related software programs.
- Excellent organizational skills.
- Must be a team player.
- Limited travel may be required.
physical requirements
- Must be able to remain in the stationary position 95% of the time
- Constantly operate a computer and other office equipment such as telephone
- Regular & predictable attendance is essential for this position
Remote but need to be local to 18702
RN preferred but LPN will be considered