Clinical Review RN - 247995

Medix provides workforce solutions to clients and creates opportunity for talent in the Healthcare, Life Sciences, Engineering and Technology fields. Through our core purpose of positively impacting lives, we have earned our reputation as an industry leader by providing unsurpassed customer service and top quality professionals to our clients.

Job Title: Clinical Review RN (Independent Dispute Resolution) Experience: Open to various clinical backgrounds/experience. Must have 2+ years of clinical experience post graduation, must has critical thinking and problem solving skills. ***Must have BSN and NYS RN license*** Location: Will start out as remote for ~6-8 months until there is enough office space and then will be asked to work in the office full time M-F. Office is in Jericho, NY. Hours of Operation: M-F 7a-5:30p *flexible start between 7am-9am (40hrs/wk) Start date: ASAP Pay: $50-53/hr DOE Volume: Will do appeals work under the IDR team handling on average 10 cases a day. These will be a mix between simple and complex cases. They will be reviewing documentation, codes, and more for out of Network bills and cost and making determinations on how to move forward based on the evidence. This individual will complete the full spectrum of activities related to State and Federal Independent Dispute Resolution (IDR) case determinations. They will conduct clinical level review, Prior Authorization, and disputed benefits review, supporting Medical Review Analysts, and Physician Consultants to ensure an appropriate and accurate process.

Conduct reviews up to and including the appeal level. This includes chart screen, compiling regulatory guidance, researching insurer requirements, complete electronic worksheets and preparing final determinations. Act as a resource for the administrative and clinical staff in training, problem solving, and clarifying determinations. Will provide technical assistance and conduct/participate in staff huddles. Training and mentoring new RNs as the project expands. Claims assessment and adjudication. Participate in collaborative training. Other activities as may be deemed necessary.