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Healthcare Claims Review Specialist

2 months ago

Atlanta, United States KARNA LLC Full time
Position Overview

Are you dedicated to enhancing healthcare outcomes? KARNA LLC is seeking a skilled Medical Claims Review Nurse to contribute to our mission of supporting individuals affected by significant health events. This role is pivotal in ensuring that claims are meticulously reviewed for medical necessity and in addressing provider appeals effectively.

Key Responsibilities:

  • Serve as a registered nurse within the Medical Management team, focusing on medical claims review.
  • Conduct thorough reviews of medical claims on a weekly basis, which includes:
    • Identifying and analyzing claims issues pending medical review.
    • Engaging in evidence-based research to support decision-making.
    • Assessing whether claims issues can be resolved internally or necessitate further client involvement.
    • Providing informed recommendations to clients based on research findings and clinical expertise.
    • Delivering weekly presentations of findings to clients.
    • Tracking and reporting on claims metrics for quality assurance.
  • Review and respond to medical claims appeals in a timely manner.
  • Collaborate with Clinical Centers of Excellence (CCEs) to gather necessary medical claims documentation.
  • Investigate medical coding and pricing using established fee schedules and methodologies.
  • Perform audits on medical claims to uphold quality standards.
  • Document all Medical Management processes, including claims review activities.
  • Conduct ad hoc research as required by clients.

Qualifications:

  • Registered Nurse (RN) licensure is required.
  • Bachelor of Science in Nursing (BSN) is preferred; a BA/BS may be considered.
  • A minimum of 5 years of experience in an acute care environment.
  • At least 2 years of experience in Utilization Review (UR), Utilization Management (UM), or Case Management is preferred.
  • Experience in claims review within an acute care setting is advantageous.
  • Relevant certifications such as Certified Case Manager (CCM) or Accredited Case Manager (ACM) are preferred.
  • Familiarity with Federal programs and payors, including CMS, OWCP, and Tricare is beneficial.
  • Proficient in medical coding systems, including ICD-10, CPT, and HCPCS.
  • Experience in Quality Assurance review of medical claims is preferred.
  • Strong analytical skills for data evaluation and reporting on UR trends.
  • Knowledge of appeals and denials processes.
  • Understanding of transitions of care.
  • Ability to identify opportunities for improving cost, quality, and utilization of care.
  • Excellent organizational skills to manage and prioritize tasks effectively.
  • Leadership abilities to mentor less experienced staff.
  • Commitment to maintaining HIPAA compliance.
  • Proficient in Microsoft Office applications.
  • Capability to obtain and maintain necessary security clearance.
  • Experience in developing medical policies and procedures is a plus.
  • Strong interpersonal and presentation skills for collaboration with multidisciplinary teams.
  • Familiarity with SharePoint is preferred.

If you possess the clinical expertise and a commitment to service excellence, we encourage you to consider this opportunity with KARNA LLC.