About this role
Role Overview
- Identifies, analyzes, and determines medical necessity, pre-existing conditions, benefit eligibility and/or individual consideration reimbursement allowances for novel and complex medical management related claims
- Acts as a member advocate to promote and coordinate the delivery of quality, cost-effective healthcare services based on medical necessity and contractual benefits
- Ensures that review and determinations meet all requirements per line of business by Regulatory and Accrediting bodies
- Identifies, documents, and escalates system and process problems
- Through analysis, determines root cause and recommends possible solutions
- Reviews physician-submitted and member-submitted claims for specified services, utilizing professional knowledge and developed criteria
- Refers cases that do not meet criteria to the Medical Director with appropriate clinical analysis and summaries
- Issues denials according to department protocols
- Documents outcome of reviews
- Maintains confidentiality of all PHI in compliance with state and federal laws
- Recognizes, documents, and reports inappropriate billing patterns or utilization trends of professional and institutional providers to appropriate business owner
- Identifies situations in which claims filing/coding guidelines are not being followed by providers
- Communicates with members and providers to obtain additional information
- Informs members, providers, and internal customers of claims status and determinations
- Performs post adjudication review of claims related to coding, billing and reimbursement
Requirements
- RN with a minimum of 3 years previous clinical experience preferably in a variety of clinical settings
- LPN with a minimum of 5 years previous clinical nursing experience preferably in a variety of clinical settings
- Must hold and maintain a valid North Carolina clinical license
Benefits
- The opportunity to work at the cutting edge of health care delivery with a team that’s deeply invested in the community
- Work-life balance, flexibility, and the autonomy to do great work
- Medical, dental, and vision coverage along with numerous health and wellness programs
- Parental leave and support plus adoption and surrogacy assistance
- Career development programs and tuition reimbursement for continued education
- 401k match including an annual company contribution