Clinical Reviewer (RN/MRE) - 300064

Des Moines, IA
Join our team!
Mar 01, 2018
Job Type
Full Time
*Eligible for Telecommuting

Job Summary

The Clinical Reviewer is responsible for reviewing documentation, making clinical determinations for payment supporting claims or prior authorization requests submitted to Medicare (Durable Medical Equipment, Professional, and/or Institutional) and/or Medicaid, and providing applicable education. This position applies clinical knowledge to assess and ensure services/items billed are reasonable and necessary, supported by national and local policies, are under accepted billing and coding practices, and meet standards of medical care.

Key Performance Indicators
  • Ability to review claims in a timely and accurate manner
  • Excellent interpersonal and communication skills and strong attention to detail
  • Understanding of Medicare & Medicaid regulations

Title: Clinical Reviewer

FLSA Category: Exempt - Learned Professional

Key Duties/Responsibilities/Accountabilities
  • Meets performance standards, quality measures, and production standards.
  • Prioritizes workload.
  • Reviews, researches, and analyzes medical records.
  • Makes independent payment determinations based on Medicare/Medicaid regulations.
  • Collaborates with peers and leadership.
  • Maintains clinical and Medicare/Medicaid related knowledge.
  • Attends and actively participates in meetings.
  • Provides recommendations for action based on reviews.
  • Identifies, creates, and provides education/training to providers/suppliers/peers on review findings and Medicare/Medicaid guidelines.
  • Evaluates processes and communicates necessary enhancements.
  • Serves as a resource for the team.
  • Enhances and develops processes.
  • May perform quality/accuracy reviews.
  • May develop and conduct effective staff training.
  • Redeterminations Only: Reviews complex appeals.



Minimum Qualifications:

Title: Clinical Reviewer
  • Current RN license or other professional medical license as outlined in the statement of work (SOW) for the state of employment.
  • 2 years' clinical experience
  • Excellent communication skills
  • Demonstrated prioritization, problem solving and organizational skills
  • Strong computer skills including Microsoft Office proficiency
  • Specific Departments Only: Working knowledge of 6 specialties and/or overpayments

Preferred Qualifications:

Title: Clinical Reviewer

Above requirements and the following:
  • Bachelors of Science (BSN) in Nursing
  • 3 years of clinical experience
  • Knowledge of Medicare or Medicaid regulations
  • Knowledge of CPT/HCPCS and ICD codes
  • CPC, CIC, COC (or other) coding certification or willingness to obtain within 2 years

  • Environment and Cognitive/Physical Demands
  • Office Environment
  • Ability to read, hear, speak, keyboard, reason, communicate effectively and problem solve
  • Requires prolonged sitting and telephone usage
  • Requires the use of office equipment such as computer terminals, telephones, copiers and printers
  • Infrequent lifting up to 15 pounds
  • Infrequent stooping
  • Travel required up to 25% for both positions

Segregation of Duties

Every employee is responsible to perform their duties and responsibilities in accordance with Noridian values, policies and procedures, including but not limited to, Segregation of Duties Principles, HIPAA Security and Privacy, CMS requirements, the Noridian Compliance Program, and any other applicable laws, rules and regulations.

Other Information

Job Posting Policy 6.05

New employees with Noridian Healthcare Solutions will be eligible to apply for positions within their assigned department after successfully completing a 90-day review. For positions outside your department, you must attain a minimum of six months of service before you can apply.

Equal Employment Opportunity
Equal Opportunity Employer of Minorities, Females, Protected Veterans and Individual with Disabilities, as well as Sexual Orientation or Gender Identity.

For questions, please email .

This job posting will be closed 3/30/2018 at 8:00AM CST. No further applications will be considered.