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Clinical Reviewer (RN/MRE) - 300064

Employer
Noridian Healthcare Solutions
Location
Open
Salary
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* This position is 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


Essential Functions

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.


Non-Essential Duties and Functions

• Other duties as assigned.

Requirements

Minimum Qualifications:
  • 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 organization skills
  • Strong computer skills including Microsoft Office proficiency
  • Specific Departments Only: Working knowledge of 6 specialties and/or overpayments

Preferred Qualifications:

Above requirements and the following:
  • 3 years' 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

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.

CMS Access Compliance and Regulation Contingency Statement

Some positions require compliance with (i) federal and agency-specific regulations and related clauses included in NHS's prime contracts with the Government, (ii) background checks, and (iii) eligibility for a government-issued identification card.

Statement of Other Duties

This document describes the essential functions, requirements, and responsibilities of this job, and is not intended to be a complete list of all tasks and functions. Employees may be requested to perform job related tasks other than those specifically listed in this description, and may be required to perform any task requested by the supervisor or by management.

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 careers@noridian.com.

This job posting will be closed 06/29/2018 at 8:00AM CST. No further applications will be considered.


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