Medical Claims Review Nurse

AltaStaff is a staffing agency currently looking for a Medical Claims Review Nurse to work with our Managed Care Client! Location: Remote (Candidates must reside in NY (outside greater NYC), FL, GA, MI, OH, WI, IA, NM, TX or KY) Pay Rate: $41 - $43.00 hourly Shift: 8-hour shifts within 6am-6pm local time after training Description: Remote (RN License Required) Position Purpose: This position will be reviewing medical patient records against standard medical criteria. Responsible for administering claims payments, maintaining claim records, and providing counsel to claimants regarding coverage amount and benefit interpretation. Monitors and controls backlog and workflow of claims.

Performs clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases, in which an appeal has been submitted, to ensure medical necessity and appropriate/accurate billing and claims processing. Identifies and reports quality of care issues. Identifies and refers members with special needs to the appropriate Healthcare program per policy/protocol. Assists with Complex Claim review; requires decision making pertinent to clinical experience Documents clinical review summaries, bill audit findings and audit details in the database Provides supporting documentation for denial and modification of payment decisions Independently re-evaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of all relevant and applicable Federal and State regulatory requirements and guidelines, knowledge of policies and procedures, and individual judgment and experience to assess the appropriateness of service provided, length of stay and level of care.