Medical Review Nurse

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POST DATE 8/14/2016
END DATE 10/23/2016

ALL's WELL Campbell, CA

Campbell, CA
AJE Ref #
Job Classification
Full Time
Job Type
Company Ref #
Required Licenses/Certifications
Min Salary
Max Salary
Salary Unit
per year


This Medical Review Nurse Position Features:
? Stable Company
? Great Benefits
? Great Pay to $130K

Immediate need for Medical Review Nurse for a well-known, stable, family-oriented organization!

The Medical Review Nurse performs comprehensive medical record and claims review to make payment determinations based on Medi-Cal or Medicare coverage, coding, and utilization of services and practice guidelines. Position requires the ability to research all available resources regarding claim status, medical necessity, and grievance.

The Medical Review Nurse performs review of procedures for post-authorization based on medical necessity, medical and behavioral health standards of care, and benefit determinations; review of suspended claims for CPT, ICD-9/ICD-10, HCPCS coding, bundling issues and modifier utilization; will utilize knowledge of correct coding guidelines, company policies, Milliman Criteria, UM Medical Policies and Medi-Cal/Medicare benefits to determine appropriate claim approval/denials. Will identify trends in provider billing/coding errors and utilizes findings to create cost saving review opportunities.

?Current California Registered Nurse (RN) or Licensed Vocational Nurse (LVN)
?Minimum three years clinical nursing experience in an area such as medical surgical, critical care, home health or skilled nursing.
?Minimum of two years of experience in utilization management, discharge planning and or quality improvement in a managed care setting.
?Medical claim auditing experience.
?Strong knowledge and experience in the use of ICD-9, HCPCS, hospital revenue codes, and DRGs.
?Current knowledge of Medi-Cal guidelines and regulations.
?Current knowledge of Medicare guidelines and regulations.
?Current working knowledge of Milliman Care Guidelines (MCG) or Mc Kesson?s Interqual
?Familiarity with HMO, IPA, and medical group contracting concepts, principles and practices.

We are an equal employment opportunity employer and will consider all qualified candidates without regard to disability or protected veteran status.

Job Experience:

RN case management, acute care experience, Claims auditing