The JobProvide 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 WillReview 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/workgroups/committees (eg, interdisciplinary workgroups, 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.
- Attentiveness.
- Interpersonal skills
What's in it for you?- Base salary range: $38.61 to $55.86 per hour
- Remote position
- An annual employee bonus program
- Robust Wellness Program
- Generous paid-time-off (PTO)
- Eleven paid holidays per year, plus 1 floating holiday, plus 1 birthday holiday
- Excellent 401(k) Retirement Saving Plan with employer match and contribution
- Robust employee recognition program
- Tuition reimbursement
- An opportunity to become part of a team that makes a difference to our members and our community every day!
We're always looking for talented people to join our team! Qualified applicants are encouraged to apply now!
