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Health Services WellCare - Nursing Careers

Medical Claims Review Nurse Job

Full Job Title: Medical Claims Review Nurse

Job Number: 1704385

Location: Phoenix, AZ

Date Posted: 10-2-2017

This position is forCare1st Health Plan in Phoenix, a WellCare Healthplans, Inc. company.

Performs case processing, clinical evaluation and completion of ER PLP reconsiderations from receipt to adjudication. Utilizes clinical knowledge to evaluate and assess the clinical necessity of ER PLP reconsiderations.

Department:Member Management Department

Reports to: Manager, Clinical Care

Location: Camelback Rd, Phoenix AZ 85016

Job Type: Hourly/Non-exempt

Essential Functions:
  • Communicates with coordinators and Medical Directors, the case disposition of ER PLP reconsiderations.
  • Reviews medical records against PLP guidelines and recommends a case disposition.
  • Applies clinical knowledge in the assessment, evaluation and interpretation of clinical notes submitted by the provider.
  • Evaluates the medical record so that patient age, time of day, severity of injury, availability of medical resources, etc. are considered when adjudicating the PLP case.
  • Documents the clinical aspects of the case and the reasoning for the determination outcome in numerous databases.
  • When appropriate, seeks additional clinical advice and recommendations to properly adjudicate the PLP case.
  • Serves in all phases of the reconsideration process from preloading of cases, case disposition and letter generation. Prepares cases for scanning and archiving.
  • Verifies eligibility, timeliness and record completeness of ER PLP cases and follows up with the provider as necessary.
  • Electronically enters claim detail information in organization applications including Sidewinder and documents receipt, disposition and other noteworthy aspects of the cases in the application.
  • Assists in resolving provider issues through the use of organizational databases and reports, communication with internal departments such as Claims and Appeals and contact/communication with ER PLP clinical coordinators and Medical Directors.
  • Participates in process development and testing of new process implementation.
  • Evaluates data input and output for accuracy and ensures compliance with data integrity and corporate compliance directives.
  • Participates in ad hoc projects that require clinical evaluation of medical records as directed by the Manager and/or Director.
  • Identifies misuse of ER utilization and resources and communicates with Manager/Director/Medical Director as needed.
  • Ensures timely processing and review of reconsiderations to meet departmental goals and state specific benchmarks for timeliness.
  • Performs other duties as directed by the Manager and/or Director.
Education: LPN licensed
Experience:
  • Minimum of 1-2 years general nursing experience.
  • Managed care experience preferred.
Licenses/Certifications:
  • LPN licensed in applicable state.
Special Skills (e.g. 2nd language):
  • Ability to review and interpret treatment plans
  • Ability to define problems, collect/interpret data, establish facts, draw valid conclusions and process work to completion. Knowledge of medical terminology and/or experience with CPT and ICD-9 coding
  • Knowledge of electronic billing systems.
Technical Skills/Requirements:
  • Proficient in Microsoft Outlook applications, including Word, Excel, Power Point and Outlook. Ability to use proprietary health care management system.

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Last Updated On: 12/9/2015