Medical Review Nurse
4 weeks ago
SCAN Health Plan is a not-for-profit organization dedicated to improving the health and well-being of older adults in the United States. With over 45 years of experience, SCAN has established itself as a leading expert in senior healthcare, serving over 280,000 members in California, Arizona, Nevada, Texas, and New Mexico.
The JobWe are seeking a skilled Medical Review Nurse to join our team. As a Medical Review Nurse, you will be responsible for reviewing and analyzing complex healthcare claims from a medical perspective, ensuring that they meet the necessary criteria for coverage and reimbursement.
Key Responsibilities:- Review and analyze pre and post-payment claims for medical necessity and appropriateness
- Perform audits and reviews of medical claims, identifying areas for improvement and recommending changes to policies and procedures
- Collaborate with medical directors and other stakeholders to ensure that claims are processed accurately and efficiently
- Stay up-to-date with changing regulations and guidelines, applying this knowledge to inform clinical decisions
- Current and active CA RN license in good standing
- 3-5 years of experience in clinical decision making, relative to Medicare patients
- Knowledge of Medicare and Medi-Cal rules and regulations, including ability to research coverage guidelines/criteria
- Background and/or training in use of nationally recognized, standardized clinical decision support criteria
- Competitive salary range: $38.61 to $61.78 per hour
- Remote work mode
- An annual employee bonus program
- Robust Wellness Program
- Generous paid-time-off (PTO)
- Eleven paid holidays per year, plus 1 additional floating holiday, plus 1 birthday holiday
- Excellent 401(k) Retirement Saving Plan with employer match
- Robust employee recognition program
- Tuition reimbursement
We are an equal opportunity employer and welcome applications from qualified candidates. Please submit your application, including your resume and cover letter, to [insert contact information].
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