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Health Services WellCare - Nursing Careers

Medical Claims Review Nurse Job

Full Job Title: Medical Claims Review Nurse/ RN

Job Number: 1802458

Location: Tampa, FL

Date Posted: 4-9-2018

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.

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.
  • 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.
Additional Responsibilities:Candidate Education:
  • Required A Bachelor's Degree in In Nursing
  • Required or equivalent work experience
Candidate Experience:
  • Required 3 years of experience in Nursing (In a Critical Care, ER, Pediatrics or surgical setting preferred)
  • Required 2 years of experience in UM or 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 Registered Nurse (RN)
  • Preferred Other Coding Certification
Technical Skills:
  • Required Intermediate Microsoft Excel
  • Required Intermediate Microsoft Outlook
  • Required Intermediate Microsoft Word
  • Preferred Intermediate Healthcare Management Systems (Generic)

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Last Updated On: 12/9/2015