CLAIMS REVIEW NURSE
MemorialCare - Tustin, CA

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Job Details:
  • About us:
    MemorialCare Medical Foundation (MCMF) works closely with physicians and other health care professionals to provide best practice medicine to improve the health and well being of individuals, families and our communities.

    Specific Job Responsibilities:

    · Perform comparison of medical records to determine the appropriateness of the provider’s medical/clinical documentation to substantiate and support charges, and compliance with CMS guidelines and related industry standards.

    · Perform medical reviews and onsite training as needed.

    · Complete routine chart audits within established timeframes.

    · Assists in identifying high-volume, high-risk coding, reimbursement and data quality problems, aggregates data and reports trends.

    · Develops reports of findings and assists with the development of corrective action plans.

    · Compile data according to set instructions or procedures, summarizing findings, provides information and makes recommendations to management.

    · Monitors and documents compliance with corrective action plan.

    · Provides and maintains communications with providers, departments, and staff as required.

    · Develops tools and procedures for audits, reports, corrective action plans, and correspondence.

    · Maintains department files and records including hard copy; and/ or electronic medical records and audit documentation per established policy and procedure

    · Resolves rejected fee tickets and claims by accurately assigning CPT, ICD-9, and HCPCS codes after careful review of chart notes.

    · Utilize medical reference resources and contacts to thoroughly research coding issues and to maintain working knowledge of payment/reimbursement systems to ensure maximum reimbursement and coding compliance.

    · Interacts with Business Center and facility staff on coding problems and initiates correspondence when necessary.

    · Maintains patient confidentiality at all times.

    · Maintains a safe and orderly work area.

    · Work as a team player and communicate in a positive manner with co-workers, managers, providers, and other contacts.

    Qualifications/Skills:

    CPT, ICD-9-CM, HCPCS coding, medical coding compliance, auditing, working knowledge of CMS regulation and billing guidelines and insurance knowledge necessary; excellent verbal and written communication skills. Intermediate knowledge of Microsoft Outlook, Microsoft Word, and Excel is mandatory.

    Experience:

    Five to seven years experience. Experience should include the medical office and hospital environment with emphasis on physician interaction.

    Education:

    Current RN/LVN License with extensive coding background. Prefer college level degree in related field. Current CCS/CPC/RHIT certification is mandatory.

Req Number: 313028

MemorialCare - 2 years ago - save job