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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.
Additional Responsibilities:Candidate Education:
Required A Bachelor's Degree in In Nursing
Required or equivalent work 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
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
Required Intermediate Microsoft Excel
Required Intermediate Microsoft Outlook
Required Intermediate Microsoft Word
Preferred Intermediate Healthcare Management Systems (Generic)