[Hiring] Medical Review Nurse @SCAN Health Insurance

Role Description

Provide clinical review of medical claims and post service appeals. Facilitate appropriate investigation of issues and management of medical services and benefits administration while maintaining SCAN timeframe standards.

• Review and analyze pre and post payment of complex health care claims from a medical perspective.
• Perform audits/reviews of medical claims per established criteria, identify need for medical record review, necessary documentation to support decision making process regarding appropriateness of claim, billed charges, benefit coverages.
• Provide guidance to other staff members and accurately interpret and apply broad Centers for Medicare and Medicaid Services (CMS) guidelines to specific and highly variable situations.
• Conduct review of claims data and medical records to make clinical decisions on the coverage medical necessity, utilization, and appropriateness of care per national and local policies as well as accepted medical standards of care as assigned and as necessary and appropriate.
• Process workload and complete project work in the appropriate computer system(s). Contribute to team effort by accomplishing related results as needed.
• Route identified clinical and/or risk issues to appropriate personnel (e.g., Medical Director, Quality of Care (QOC) Nurse, Medical Management Specialist, Member Services, etc.).
• Review/prepare potential claims denials in conjunction with Medical Director.
• Collaborate with Medical Director pursuant to adjudication of claims and post service appeals.
• Participate in special projects/workgroups/committees (e.g., interdisciplinary workgroups, report analysis, independent review entity (IRE), etc. as assigned and as necessary and appropriate).
• Actively support the achievement of SCAN’s Vision and Goals.
• Other duties as assigned.

Qualifications

• Associate's Degree or equivalent experience required.
• Current and active California RN License in good standing required.
• Bachelor's Degree or equivalent experience preferred.
• Certified Professional Coder preferred.
• 3-5 years of related experience in clinical decision making relative to Medicare patients.
• Certifications deemed to be reasonable to function at this level.
• Performs work under minimal supervision.
• Handles complex issues and problems and refers only the most complex issues to higher-level staff.
• Possesses comprehensive knowledge of subject matter.
• Strong technical skills for functional area.
• Strong problem-solving skills.
• Good communication and interpersonal skills.
• Ability to work as part of a team.
• Oral and written communication skills.
• Attentiveness.
• Interpersonal skills.

Benefits

• Base salary range: $38.61 to $55.86 per hour.
• Remote position.
• An annual employee bonus program.
• Robust Wellness Program.
• Generous paid-time-off (PTO).
• Eleven paid holidays per year, plus 1 floating holiday, plus 1 birthday holiday.
• Excellent 401(k) Retirement Saving Plan with employer match and contribution.
• Robust employee recognition program.
• Tuition reimbursement.
• An opportunity to become part of a team that makes a difference to our members and our community every day!

Company Description

Founded in 1977 as the Senior Care Action Network, SCAN began with a simple but radical idea: that older adults deserve to stay healthy and independent. Today, SCAN is a nonprofit health organization serving more than 500,000 people across Arizona, California, Nevada, New Mexico, Texas, and Washington, with over $8 billion in annual revenue.

SCAN Group is a not-for-profit organization dedicated to tackling the most pressing issues facing older adults in the United States. SCAN has been a mission-driven organization dedicated to keeping seniors healthy and independent for more than 45 years and is known throughout the healthcare industry and nationally as a leading expert in senior healthcare.

Employees are provided in-depth training and access to state-of-the-art tools necessary to do their jobs, as well as development and growth opportunities. SCAN takes great pride in recognizing our team members as experts in their fields and rewarding them for their efforts.