Medical Claims Review Nurse II

HMA is the premier third-party health plan administrator across the PNW and beyond. We relentlessly deliver on our promise to provide medium to large-size employers with customized health plans. We offer various high-quality, affordable healthcare plan options supported with best-in-class customer service. We are proud to say that for four years, HMA has been chosen as a ‘Washington’s Best Workplaces’ by our Staff and PSBJ™. Our vision, ‘Proving What’s Possible in Healthcare™,’ and our values, People First!, Be Extraordinary, Work Courageously, Own It, and Win Together, shape our culture, influence our decisions, and drive our results.

What we are looking for: We are always searching for unique people to diversify our team. We only hire people that care deeply about others, thrive in evolving environments, gain satisfaction from being part of a team, are motivated by tackling complex challenges, are courageous enough to share ideas, action-oriented, resilient, and results-driven. What you can expect: You can expect an inclusive, flexible, and fun culture, comprehensive salary, pay transparency, benefits, and time off package with plenty of personal development and growth opportunities. If you are looking for meaningful work, a clear purpose, high standards, work/life balance, and the ability to contribute to something important, find out more about us at: https://www.accesshma.com/ How YOU will make a Difference: The Medical Claims Review Nurse provides monitoring of member utilization and claim patterns using clinical nursing knowledge and coding expertise to oversee the accuracy of claims for medically necessary care provided to our members. This work promotes the integrity of claim payment to support fiscal responsibility of payments. This nurse also works in conjunction with the Appeals team providing clinical expertise and performs high-level writing skills.

Analyzes claims against clinical documentation using coding and clinical expertise Clinical support of the Hospital Bill Review process Retrospective utilization management case review Extrapolates and summarizes medical information for medical directors and other external entities Ensures that reviews and appeals are resolved timely to meet regulatory timeframes Generates written correspondence to providers, members, brokers and clients