Optima Health - Virginia Beach, VA

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The Clinical Claims Reviewer reviews claims which either have not previously been authorized for payment or have a clinical coding issue and determination of payment by determining medical necessity and correct coding of provider and facility claims. Acts a resource for other departments, Operations, Member and Provider Services, Network Management, Marketing, etc. in interpretation of benefits, resolution of provider/member complaints or inquiries, and the processing of suspended claims.

Responsibilities include review and determination of provider reconsiderations. Review of procedures for post-authorization based on medical necessity and benefit determinations. The nurse audits Medical Records to review for accurate provider CPT, HCPCS, ICD-9, modifier, and revenue code billing. Has expert knowledge of Claims Xten (Claims scrubbing software) and assists other departments and providers with software denial justifications. The nurse makes claims payment determinations on lines Claims Xten pends for review. Utilizes knowledge of medical and behavioral health standards of care guidelines, correct coding guidelines, plan policies, and group benefits to determine claim approval/denial. Assists multiple departments with research projects. Acts as a resource to the Case Management staff to identify members requiring Community Based Case Management. Identifies trends in provider billing/coding errors and utilizes findings to create cost saving review opportunities. Coordinates and collaborates with multiple departments to assist in developing processes which facilitate accurate and compliant claims payment.

Requirements: Graduate of an accredited school of professional nursing (RN) required. Minimum of 3 years acute care experience required. Minimum of 1 year coding or billing experience required.

Licensure: Current Commonwealth of Virginia Registered Nurse licensure required. Certified Professional Coder (CPC) required within 1 year from date of hire.

Other: Ability to pass a basic computer skills test required; knowledge of CPT coding required; basic knowledge of billing processes required; mathematical skills required to calculate payment amounts of certain codes and modifiers based on set formulas.

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