Medical Review Nurse

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About the position

The Medical Review Nurse provides clinical review of medical claims and post-service appeals, facilitating appropriate investigation of issues and management of medical services and benefits administration while meeting SCAN timeframe standards. The role reviews and analyzes complex healthcare claims before and after payment, evaluates clinical documentation and medical records, and makes decisions about coverage, medical necessity, utilization, and appropriateness of care in accordance with applicable policies and accepted standards of care. The position works with a Medical Director and other teams on claims adjudication, potential denials, and clinical or risk issues. It also contributes to projects, workgroups, and committees, supports SCAN’s vision and goals, and uses curiosity about AI to help transform operations and member service. This is a remote position.

Responsibilities

  • Review and analyze complex healthcare claims from a medical perspective, both before and after payment.
  • Audit and review medical claims against established criteria; identify when medical-record review is needed and what documentation is required to support decisions about claim appropriateness, billed charges, and benefit coverage.
  • Guide other staff members and interpret and apply CMS guidelines to varied situations.
  • Review claims data and medical records to make clinical decisions concerning coverage, medical necessity, utilization, and appropriateness of care under national and local policies and accepted medical standards.
  • Process workload and project work in appropriate computer systems and contribute to team efforts.
  • Route identified clinical or risk issues to appropriate personnel, such as a Medical Director, Quality of Care Nurse, Medical Management Specialist, or Member Services.
  • Review and prepare potential claims denials in conjunction with a Medical Director.
  • Collaborate with a Medical Director on adjudication of claims and post-service appeals.
  • Participate in special projects, workgroups, and committees as assigned, including interdisciplinary workgroups, report analysis, and independent review entity activities.
  • Actively support the achievement of SCAN’s vision and goals and perform other duties as assigned.

Requirements

  • Associate’s degree or equivalent experience.
  • Current and active California RN license in good standing.
  • 3–5 years of related experience in clinical decision-making relative to Medicare patients.
  • Certifications reasonably needed to function at this level.
  • Ability to perform work under minimal supervision and handle complex issues, referring only the most complex issues to higher-level staff.
  • Comprehensive knowledge of the subject matter and strong technical skills for the functional area.
  • Strong problem-solving skills.
  • Good oral and written communication and interpersonal skills.
  • Ability to work as part of a team.
  • Attentiveness.

Nice-to-haves

  • Bachelor’s degree or equivalent experience.
  • Certified Professional Coder certification.

Benefits

  • Annual employee bonus program
  • Robust wellness program
  • Generous paid time off
  • Eleven paid holidays per year, plus one floating holiday and one birthday holiday
  • 401(k) retirement savings plan with employer match and contribution
  • Employee recognition program
  • Tuition reimbursement
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