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Medical Claims Review Specialist
2 months ago
Role Summary
The Medical Claims Review Specialist plays a crucial role in the thorough examination and interpretation of clinical records and claim documents to facilitate the appeals process for denied insurance claims. Key responsibilities include composing appeal letters grounded in clinical expertise and knowledge. This role offers the flexibility of remote work, with the option to work on-site if preferred. Occasionally, the specialist may be asked to conduct in-person training sessions or seminars for staff, with prior notice.
Work Schedule
This is a part-time role with the possibility of transitioning to full-time. Initially, the position requires a commitment of 15 hours per week, with the potential for increased hours based on the workload and the candidate's availability.
Key Responsibilities
This list is not exhaustive; additional duties may be assigned. Candidates should be familiar with various types of hospital documentation, including but not limited to medical records, UB-04 forms, EOBs, itemized bills, hospital account notes, appeal letters, and denial/approval notifications.
- Utilize TimeMatters for work assignments and to communicate claim notes clearly and concisely.
- Analyze and interpret medical records and claim documentation (such as EOBs and UB-04s) to support appeals for denied insurance claims related to both inpatient and outpatient services.
- Employ clinical judgment and knowledge regarding medical necessity, admissions, and other clinical evaluations.
- Draft, review, and refine appeal letters, including those prepared by other team members.
- Ensure adherence to correct letter formats, guidelines, and logical arguments.
- Verify that letters are coherent and easily understandable.
- Confirm that all necessary attachments are included with the appeal.
- Ensure page number citations correspond accurately with the medical records.
- Expedite high-value and/or urgent cases promptly.
- Submit all appeals, follow-ups, and documentation within the required filing periods.
- Comply with all HIPAA regulations and other compliance standards.
- Assist in developing clinical training materials for team members.
- Support the clinical training of staff.
Qualifications
A Bachelor's degree from an accredited four-year institution is required. The Medical Claims Review Specialist should hold a valid license as a Registered Nurse (including RN, APRN, CRNP), Nurse Practitioner (including CNP, LNP, NPC), Physician Assistant, Physician, or another qualified healthcare professional. Current active licensure is not mandatory.
Compensation and Benefits
- Hourly rate starting at $45, commensurate with qualifications.
- Eligibility for monthly performance bonuses after a designated period of employment.
- Upon transition to full-time status, additional benefits such as 401k, health insurance, disability coverage, and commuter benefits will be available.
