Claims Review Nurse

First Choice Health
Full time
United States
Hiring from: Anywhere

Title: Claims Review Nurse – Telecommute

  • Location: United States

Job Summary

Under the direction of the Supervisor of Clinical Operations, the Claims Review Nurse is responsible for the review of claims that require evaluation for medical necessity, clinical interpretation, and evaluation of appropriate coding.

Main Duties

  • Performs claims review, using clinical expertise/judgment, to establish medical necessity and appropriateness of services in compliance with established medical policy, community standards, and the member’s plan documents.

  • Performs claims review for the evaluation of appropriate coding and billing processes. This includes proper bundling of codes, proper use of modifiers, and when and how to use multiple codes for the same procedure.

  • Routes cases that do not meet medical management policies and guidelines to the Medical Director following established processes.

  • Utilizes analytical skills to identify problems, develop solutions, and implement a course of action within an acceptable interpretation of departmental policies and procedures. This includes recognition of any trends of unusual billing or clinical practices.

  • Identifies, investigates, and reports to the manager possible any trends of unusual billing practices, quality of care issues, or fraud and abuse discovered during reviews.

  • Works closely with claims staff to ensure claims are processed as directed and participates in intra-departmental meetings as requested.

  • Participates in Code Review Committee, quality improvement projects, continuing education, and Medical Management programs as required.

  • Identifies and refers patients to case management, behavioral health, stop loss, subrogation, quality and external vendors for health and wellness services based on the appropriate guidelines and payor requirements.

  • Provides consistent and accurate case documentation using FCH applications.

  • Creates member correspondence using plain language and ensuring compliance with internal policies and procedures.

  • Acts as a liaison to members, participants, providers of care, and, when appropriate to payers.

  • Other duties as assigned.


  • Current unrestricted Registered Nurse license required.

  • Certified Coder (CPC or other nationally recognized organization) or 2 years of coding experience using CPT, ICD-9, and HCPCS codes in a claims review setting.

  • Minimum of three (3) years full time equivalent of direct clinical care to patients. Hospital experience preferred.

  • Knowledge of the principles of prospective, concurrent, and retrospective clinical review, and continuous quality improvement preferred.

  • Two to three years experience in an HMO, PPO or related health care industry.

  • Proficiency in PC Applications including Word, Excel and Outlook.

  • Demonstrates analytical ability to identify problems, develop solutions and implement a course of action within an acceptable interpretation of departmental policies and procedures.

  • Professional demeanor, functions well in stressful situations, and prioritizes well with minimal direction.

  • Excellent problem solving, negotiation and conflict resolution skills.

  • Ability to demonstrate strong written, verbal and interpersonal communication skills with varying levels of internal and external agencies and medical professionals.

Our Benefits

  • Become a First Choice Health employee and enjoy our generous benefit package. We offer competitive benefits that are much beyond the traditional basics.

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