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Medical Claims Reviewer
1 month ago
SCAN Group is a not-for-profit organization dedicated to addressing the most pressing issues affecting older adults in the United States. As a leading expert in senior healthcare, SCAN has been a mission-driven organization for over 45 years, committed to keeping seniors healthy and independent. Our team of talented professionals is passionate about supporting older adults on their aging journey, while innovating healthcare for seniors everywhere.
The JobWe are seeking a skilled Medical Claims Reviewer to join our team. As a Medical Claims Reviewer, you will be responsible for reviewing and analyzing complex healthcare claims from a medical perspective. Your expertise will be essential in ensuring that claims are processed accurately and efficiently, while maintaining SCAN's high standards of quality and care.
Key Responsibilities:- Review and analyze pre and post payment of complex healthcare claims from a medical perspective.
- Perform audits/reviews of medical claims per established criteria, identifying the need for medical record review and necessary documentation to support decision-making.
- Provide guidance to other staff members and accurately interpret and apply broad Centers for Medicare and Medicaid Services (CMS) guidelines to specific and highly variable situations.
- Conduct review of claims data and medical records to make clinical decisions on coverage, medical necessity, utilization, and appropriateness of care per national and local policies and accepted medical standards of care.
- Process workload and complete project work in the appropriate computer system(s).
- Route identified clinical and/or risk issues to appropriate personnel, such as the Medical Director, Quality of Care (QOC) Nurse, Medical Management Specialist, Member Services, etc.
To be successful in this role, you will need:
- A completed Nursing Degree or Diploma.
- A current and active CA RN License in good standing.
- Certified Professional Coder preferred.
- 3-5 years of experience in clinical decision-making, relative to Medicare patients.
- Experience using claims processing systems.
- Knowledge of Medicare and Medi-Cal rules and regulations, including the ability to research coverage guidelines/criteria.
- Background and/or training in the use of nationally recognized, standardized clinical decision support criteria, as applicable to ensure consistency in clinical review.
- Experience/knowledge in the appeals/claims processing procedures in Managed Care or similar experience.
- Working knowledge of the Managed Care regulatory agencies and the applicable laws and regulations.
We offer a competitive salary range of $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 one additional floating holiday, plus one birthday holiday, excellent 401(k) Retirement Saving Plan with employer match, robust employee recognition program, tuition reimbursement, and an opportunity to become part of a team that makes a difference to our members and our community every day.
