Job Description: Pay Range: $34hr - $39hr Essential Functions:
- 35% Receives, researches, reviews and analyzes professional and institutional claims using critical thinking, nursing clinical judgment and corporate/medical policies for claims processing and/or adjudication, Performs high-level research on topics identified as actual or potential medical policies.
- Assesses and communicates impact of information on medical policy.
- 25% Provides pricing of procedure codes which require individual consideration or are listed as not otherwise classified in CPT manual.
- Interprets the descriptive or medical information utilizing the CPT and HCPCS manuals.
- Keeps up-to-date on coding rules and standards.
- 25% Participates in medical policy meetings, nurses' forums, and review sessions with Medical and Dental directors, special projects and task forces committees as assigned.
- 15% Performs medical underwriting and risk assessment by reviewing applications of potential subscribers, as well as any appropriate medical records.
Experience:
- 3 years acute clinical experience, previous case management, discharge planning or utilization review experience.
Preferred Qualifications:
- Bachelor's degree in Nursing.
Knowledge, Skills and Abilities:
- Ability to effectively communicate and provide positive customer service to every internal and external customer, Proficient.
- Strong interpersonal skills.
- Ability to work independently, as well as a member of a team , Advanced.
- Current knowledge of clinical practices and related medical policies.
- Proficient
- Strong organizational skills, ability to prioritize responsibilities with attention to detail., Proficient.
- Experience in using Microsoft Office (Excel, Word, Power Point, etc.) and web-based technology., Proficient.
- Electronic Medical Record Retrieval Experience.
- Must possess excellent verbal and written communication skills. , Advanced
- Licenses/Certifications.