Clinical Claims Review Nurse

Department: Health Services - Inpatient Care Management

Reports to: Director, Utilization Management

Location: Tampa, FL 33634

Job Type: Hourly/ Non-Exempt

Position reviews and audits clinical information (post service, prepayment medical claims) to determine appropriateness of charges in accordance with contracted payor terms, standards of care and Medicare/Medicaid requirements. Works with internal and external partners (physicians, members, payors and other healthcare providers) in support of appropriate utilization and timely reimbursement of healthcare services.

Essential Functions:

  • Evaluates medical claims and/or medical records by applying clinical expertise to assess appropriateness of service provided, length of stay and level of care. Identifies and refers all cases not meeting medical necessity criteria and guidelines to appropriate decision maker for review.
  • Reviews claims at the post service, prepayment level and identifies and reports discrepancies, including quality of care issues.
  • Evaluates and intervenes as needed for level of care, denial and compliance issues.
  • Assists with Complex Claim review; requires decision making pertinent to clinical experience.
  • Documents clinical review summaries, bill audit findings and audit details in the system.
  • Provides supporting documentation for denial and modification of payment decisions.
  • Reviews readmission claims for appropriate DRG coding and medical necessity.

Candidate Education:

  • Required An Associate's Degree in in Nursing
  • Required Other Or equivalent work experience in a health care related field
Candidate Experience:
  • Required 3 years of experience in general nursing with the preference in critical care/ER/surgical setting
  • Required 1 year of experience in Medical Claims Review (1 of the 3 years of experience must be in medical claims review)
Candidate Skills:
  • Intermediate Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
  • Intermediate Ability to work as part of a team
  • Advanced Ability to work in a fast paced environment with changing priorities
  • Advanced Ability to work independently
  • Intermediate Demonstrated analytical skills
  • Intermediate Demonstrated problem solving skills
  • Advanced Demonstrated written communication skills
  • Advanced Knowledge of medical terminology and/or experience with CPT and ICD-10 coding
  • Intermediate Other Knowledge of Milliman or InterQual guidelines
Licenses and Certifications:
A license in one of the following is required:
  • Required Other One of the following licenses is required: LPN, RN
Technical Skills:
  • Required Intermediate Microsoft Excel
  • Required Intermediate Microsoft Outlook
  • Required Intermediate Microsoft Word
  • Preferred Intermediate Healthcare Management Systems (Generic)

About us
Headquartered in Tampa, Fla., WellCare Health Plans, Inc. (NYSE: WCG) focuses primarily on providing government-sponsored managed care services to families, children, seniors and individuals with complex medical needs primarily through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans, as well as individuals in the Health Insurance Marketplace. WellCare serves approximately 5.5 million members nationwide as of September 30, 2018. WellCare is a Fortune 500 company that employs nearly 12,000 associates across the country and was ranked a "World's Most Admired Company" in 2018 by Fortune magazine. For more information about WellCare, please visit the company's website at EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, creed, age, sex, pregnancy, veteran status, marital status, sexual orientation, gender identity or expression, national origin, ancestry, disability, genetic information, childbirth or related medical condition or other legally protected basis protected by applicable federal or state law except where a bona fide occupational qualification applies. Comprehensive Health Management, Inc. is an equal opportunity employer, M/F/D/V/SO.