Clinical Claims Nurse

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$30.00/hr - $30.25/hr

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Job Title: Clinical Claims Nurse (Healthcare Provider)

Job Type: 4-month Contract to Hire

Location: Remote, United States

Salary Range: $36.25 an hour

Hours: Core Hours M-F, 9-3 PM EST

Position Overview:

This role supports individuals such as patients, beneficiaries, and healthcare providers by reviewing submitted documentation to evaluate the validity of appeals or disputes. It involves delivering a fair and unbiased second-level decision based on an in-depth analysis of facts, supporting documentation, applicable laws, and relevant guidelines.

Key Responsibilities:

• Analyze medical records and case files to produce clear, objective reconsideration or dispute resolution summaries that justify the final determination.
• Exercise independent judgment to make evidence-based decisions in alignment with legal statutes, established regulations, policies, and clinical standards.
• Address and respond thoroughly to all issues presented by patients, beneficiaries, authorized representatives, or healthcare providers involved in the appeal or dispute.
• Render impartial conclusions supported by current evidence, policy, and regulatory frameworks.
• Conduct detailed research utilizing online resources such as federal regulations, medical standards, policy manuals, and clinical literature to support accurate, well-informed decisions.
• Stay informed of developments in healthcare practices, legal regulations, and organizational policies to ensure decisions remain compliant and current.

Required Qualifications:

Education:

• Associate’s degree or higher in a healthcare-related field from an accredited institution.
• LPN or RN License

Experience:

• Minimum of three (3) years’ experience in medical appeals, dispute resolution, clinical review, or a related healthcare environment.
• Background in Nursing, Physical Therapy, Occupational Therapy, or Respiratory Therapy is required.
• Candidates holding a Juris Doctorate or a Master’s in a healthcare-related discipline may substitute this requirement.
• Proven ability to compose or assess appeals and payment-related determinations.
• Preferred experience with patient-provider or independent dispute resolution processes.
• Possession of a coding certification is a plus.

Benefit offerings available for our associates include medical, dental, vision, life insurance, short-term disability, additional voluntary benefits, EAP program, commuter benefits and a 401K plan. Our benefit offerings provide employees the flexibility to choose the type of coverage that meets their individual needs. In addition, our associates may be eligible for paid leave including Paid Sick Leave or any other paid leave required by Federal, State, or local law, as well as Holiday pay where applicable.

Equal Opportunity Employer/Veterans/Disabled

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The Company will consider qualified applicants with arrest and conviction records in accordance with federal, state, and local laws and/or security clearance requirements, including, as applicable:

The California Fair Chance Act

Los Angeles City Fair Chance Ordinance

Los Angeles County Fair Chance Ordinance for Employers

• Seniority level
  
  Mid-Senior level

• Employment type
  
  Contract

• Job function
  
  Health Care Provider
• Industries Hospitals and Health Care

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