Medical Review Nurse - RN

Medical Review Nurse - RN page is loaded## Medical Review Nurse - RN locations:
Long Beach Office 3800time type:
Full time posted on:
Posted 2 Days Agojob requisition :
JR2306

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. That belief was championed by a group of community activists we still honor today as the “12 Angry Seniors.” Their mission continues to guide everything we do.

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. With nearly five decades of experience, we have built a distinctive, values-driven platform dedicated to improving care for older adults.

Our work spans Medicare Advantage, fully integrated care models, primary care, care for the most medically and socially complex populations, and next-generation care delivery models. Across all of this, we are united by a shared commitment: combining compassion with discipline, innovation with stewardship, and growth with integrity.

At SCAN, we believe scale should strengthen—not dilute—our mission. We are building the future of care for older adults, grounded in purpose, accountability, and respect for the people and communities we serve.
** The Job
** 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.
** You Will
** 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 eg, 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/work groups/committees (eg, interdisciplinary work groups, report analysis, independent review entity (IRE) etc. as assigned and as necessary and appropriate.

We seek Rebels who are curious about AI and its power to transform how we operate and serve our members.

Actively support the achievement of SCAN’s Vision and Goals.

Other duties as assigned.
** Your 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.

- Technical expertise - Strong technical skills for functional area  - Problem Solving - Strong problem-solving skills  - Communication - Good communication and interpersonal skills
- Ability to work as part of a team.  - Oral and written communication skills.  - Problem-solving skills.  -…