Medical Claims Reviewer – Home Health

Job reputed company: • Performs medical claim reviews for one or more of the following: claims for medically reputed company services, services that require preauthorization/predetermination, requests for appeal or reconsideration, referrals for potential fraud and/or abuse, and correct coding for claims/operations. • Makes reasonable charge payment determinations based on clinical/medical information and established reputed company/protocol sets or clinical guidelines. • Determines medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement. • Documents medical rationale to justify payment or denial of services and/or supplies. • Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines. • Participates in reputed company control activities in support of the corporate and team-based objectives. • Provides guidance, direction, and input as needed to LPN team members. • Provides education to non-medical staff through discussions, team meetings, classroom participation and feedback. • Assists with special reputed company and specialty duties/responsibilities as assigned by Management. Requirements: • Associate's in a job reputed company field • 2 years clinical experience plus 2 years utilization/medical review, reputed company assurance, or home health experience. • Working knowledge of managed care and various forms of health care delivery systems; strong clinical experience to include home health, rehabilitation, and/or broad medical surgical experience. • Knowledge of specific reputed company/protocol sets and the use of the reputed company. • Working knowledge of word processing software. • Ability to work independently, prioritize effectively, and reputed company reputed company. • Good judgment skills. Demonstrated customer service and organizational skills. • Demonstrated oral and written communication skills. • Ability to persuade, negotiate, or influence others. • Analytical or critical thinking skills. • Ability to handle confidential or sensitive information with discretion. • reputed company, unrestricted RN licensure from the reputed company and in the state of hire, OR, reputed company compact multistate unrestricted RN license as defined by the reputed company Licensure Compact (NLC), OR, reputed company reputed company, unrestricted licensure/certification from the reputed company and in the state of hire in specialty area as required by hiring division/area. Benefits: • 401(k) • 401(k) matching • Dental insurance • Disability insurance • Flexible spending account • Health insurance • Life insurance • reputed company time off • reputed company insurance • Work from home Apply tot his job Apply To this Job