Claims Review Nurse

Job Details

Job Location:

Remote - Remote Employees, VA 12345

About Capitol Bridge

Founded in 2012, Capitol Bridge is based in Arlington, Virginiaandhasprovenexpertiseproviding independent medical reviews, records/data management services, medical coding, administrativestaffingand eligibility reviews.

Capitol Bridge is actively seeking an experienced

Claims Review Nurse. The Claims Review Position will play a crucial role in the Florida Statewide Health Plan Claim Dispute Resolution(FL CDR)
Program under the Agency for Health Care Administration and Independent Review Organization (IRO) programs for multiple States. This position is integral to ensuring fair and efficient resolution of claim disputes.

You willbe responsible for resolving claim disputessubmittedby various parties such as physicians, hospitals, institutions, pharmacies, and other licensed healthcare providers.

Forthe FloridaCDR program,you willassistcontracted and non-contracted health care providers and health care planswithresolution ofclaimdisputes within the parameters of Section 408.7507, Florida Statutes and Rule 59A-12.030, Florida Administrative Codes.

Additionally, your responsibilities will include resolving disputessubmittedto various State’sIndependent Review Organization (IRO) programs. IROsconduct impartial reviews of healthcare services to resolve disputes between patients, healthcare providers, and payers.

IROsprovide objective assessments of medical necessity, appropriateness of care,billing, coding,and other issues related todisputed claims.

Your role requires conducting all job duties efficiently, promptly, productively, consistently, and courteously, whilemaintaininga high levelof professionalism.

Salary Range:$75-85k

• Conductan initial assessment of documentation from boththeinitiating and responding parties.
• Reviewsubmitteddocumentation toidentifymissing documents anddeterminewhat isrequiredto resolve the dispute. Follow procedures to obtain theappropriatedocumentation.
• Determinetheappropriate typeof clinical reviewernecessaryto complete thecase,such as a medical coder, or physician.
• Prepare documents for the clinical reviewer assigned and provide instruction as needed.
• Collaborate with the legal team tofacilitateresolution of disputes.
• Draftprofessional determination letters.
• Communicate with Enrollees, Health Plans, and/or Providers as neededto resolve disputes.
• Follow establishedproceduresto ensuretimelydelivery of determinations.
• Familiarizationof Current Procedural Terminology (CPT) codes.
• Participation inrequiredmeetings.
• Collaborate with credentialed clinical professionalstodeterminethemedical necessity of each service/procedure at issue in a dispute.
• Utilizegovernmental andprofessionalguidelines to supportthedeterminationontheappropriateness of each service/procedure listed in a dispute.
• Adhere to company policies, state regulations, and specific project guidelines.
• Maintain effective communication.
• Ensuretimelycompletion ofreviewswithin assigned deadlines.
• Follow established
  
  Quality Assurance/Quality Controlprocesses and meet company/departmental standards.
• Uphold scheduling commitments and privacy regulations.
• Perform other related duties as directed by leadership.

You will receive a request for a background checkregardingthis employment opportunity. Employment is contingent on successful passing of a background check.

If you require alternative methods of application or screening, you must approach the employer directly to request this. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may bemadeto enable individuals with disabilities to perform essential functions. Other duties may be assigned.

Capitol

BridgeLLC. is an Equal Opportunity Employer. All employment decisions at Capitol Bridge are based on business needs, job requirements, and individual qualifications,without regard to race, color, religion or belief, national, social, or ethnic origin, sex (including pregnancy), age, physical, mental or sensory disability, HIV Status, sexual orientation, gender identity and/or expression, marital, civil union or domestic partnership status, past or present military service, family medical history or genetic information, family or parental status, or any other status protected by the laws or regulations in the locations where we operate.

We communicate with applicants by text in addition to email and phone.

If you apply for this position, we may text you about this position, your application for the position, or other things relevant tothis job position.

If we text you and you no longer want us to text you, you can opt-out at that time.

• Maintain an active licenseinnursing.
• Five yearsoffull-time equivalent experience providing direct care to patients.
• Hold a…