Medical Review Nurse

4 weeks ago


Long Beach, California, United States SCAN Health Plan Full time
About SCAN Health Plan

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 Job

We 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
Requirements:
  • 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
What We Offer
  • 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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