Clinical Claims Nurse (Healthcare Provider)

This role supports individuals such as patients, beneficiaries, and healthcare providers by reviewing submitted documentation to evaluate the validity of appeals or disputes. It involves delivering a fair and unbiased second-level decision based on an in-depth analysis of facts, supporting documentation, applicable laws, and relevant guidelines. Pay Range: $30-$36.25/hr. The rate may be negotiable based on experience, education, geographic location, and other factors.

Analyze medical records and case files to produce clear, objective reconsideration or dispute resolution summaries that justify the final determination. Exercise independent judgment to make evidence-based decisions in alignment with legal statutes, established regulations, policies, and clinical standards. Address and respond thoroughly to all issues presented by patients, beneficiaries, authorized representatives, or healthcare providers involved in the appeal or dispute. Render impartial conclusions supported by current evidence, policy, and regulatory frameworks. Conduct detailed research utilizing online resources such as federal regulations, medical standards, policy manuals, and clinical literature to support accurate, well-informed decisions. Stay informed of developments in healthcare practices, legal regulations, and organizational policies to ensure decisions remain compliant and current.