Medical Claims Reviewer Nurse, Behavioral Health
1 week ago
Medix Healthcare
Remote - RN License Compact REQUIRED
$40.00-$42.00 an hour - Full-time
Contract Position - Expected Duration Sept-Oct 2024 or LONGER
Qualifications
Active Registered Nurse License, Multi-State (AZ Included)
2+ Years of Clinical Behavioral Health Experience (acute care hospital, OP clinic setting, detox, etc)
2+ Years of Chart Review Experience from a MCO (Insurance Side-NOT Facility)
Full Job Description
Are you a Registered Nurse that is looking to join a progressive organization that specializes in projects related to Quality Improvement?
We are looking to hire a Registered Nurse to support our Claims Review-Behavioral Health functions of both inpatient and outpatient services This will provide assurance to our members that they are getting the access to treatments they require.
This position is a contract-temp role that is expected to last through September - No guarantees
What we provide to you as a full-time teammate:
We offer a competitive benefits package that is on par with most of the leading healthcare organizations, along with a 401K plan.
Requirements
Summary:
The RN will utilize standard criteria to review post-service and prepayment reviews of OP Behavioral Health claims.
The nurse will utilize HCPC codes (ex H0004, H2017, S9480, etc) to ensure claims are being charted for correct processing of Arizona Medicaid-AHCCCS requirements.
Essential Duties and Responsibilities:
Include the following, other duties may be assigned.
As a Registered Nurse (Medical Claims Reviewer - Behavioral Health), you will...
Conduct telephonic reviews for inpatient facilities for both concurrent and retrospective reviews for appropriateness of treatment setting reviews to ensure compliance with applicable criteria.
Process Prior Authorization requests for medical necessity of Outpatient services including Rehab, Home Health and DME.Apply clinical expertise and judgment to ensure compliance with medical policy, medical necessity guidelines, and accepted standards of care.
Utilize evidence-based criteria that incorporates current and validated clinical research findings.
Practice within the scope of their license.
Provide care coordination for members who are transitioning from one level of care to another.
Gather clinical information to assess and expedite care needs.
Collaborate with providers to assess members, needs for early identification of and proactive planning for discharge, transfer and redirection.
Identify barriers to efficient utilization and facilitate resolution.
Collaborate with other departments to resolve claims, quality of care, member or provider issues.
Identify problems or needed changes, recommends resolution, and participates in quality improvement efforts.
Maintain and enhance relationships between the business and the provider community.
Provide consistent and accurate documentation.
Plan, organize and prioritize assignments to comply with performance standards, corporate goals, and established timelines.
Consult with physician advisors to ensure clinically appropriate determinations.
Expectations of Performance:
The employee in this role shall be considered to be performing in an acceptable manner when carrying out the Core Values:
Problem Solver
Adaptability
Analytical
Team Player
Time Management and Efficiency
Education and/or Experience:
Active Registered Nurse License, Multi-State (AZ Included)
3+ Years of Experience in Claims Review, OP Behavioral Health
Experience in Pre-Certification Review of Subacute Detox Admissions & Continued Stay
Clinical Experience (IP/OP) in a Behavioral Health Setting
Computer Skills:
To perform this job successfully, an individual should have knowledge of basic office equipment such as: "EMR" - (electronic medical record system), Microsoft Office, computer, internet, email, copy and fax machines, and telephone.
Benefits:
401(k)
Dental insurance
Vision insurance
Medical insurance
AD&D
Short and long term disability
PTO
Critical Illness
Schedule:
M-F, 8am-5pm (Employees Timezone)
Equipment Provided:
Laptop, monitors, cell
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