Location: Henderson Rd, Tampa, FL 33634
Department: Health Services
Reports to: Sr. Director, Strategic Initiatives
Position reviews and audits clinical information (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.
- 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.
- Identifies and reports quality of care issues.
- Evaluates and intervenes as needed for level of care, denial and compliance issues.
- Identifies and refers members with special needs to the appropriate Wellcare Healthcare program per policy/protocol.
- 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.
- Required: Bachelor's Degree in nursing; or equivalent work experience
- Required: 3 years of experience in nursing (Critical care, ER, pediatrics, surgical setting, or related)
- Required: 2 years of experience in utilization management or medical claims review
Licenses and Certifications:
- Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
- Ability to work as part of a team
- Ability to work in a fast paced environment with changing priorities
- Ability to work independently
- Demonstrated analytical skills
- Demonstrated problem solving skills
- Demonstrated written communication skills
- Knowledge of medical terminology and/or experience with CPT and ICD-10 coding
- Knowledge of Milliman or InterQual guidelines
A license in one of the following is required:
- Required: Registered Nurse (RN)
- Preferred: Coding Certification
- Microsoft Excel
- Microsoft Outlook
- Microsoft Word
- Healthcare Management Systems