What are the responsibilities and job description for the Claims Processor- RN license position at Corelleaf Design Studio?
Descrption:
Claims Processor- RN license
The Role will be focused on the review and adjudication of Federal Emergency Services (FES) 1500 claim forms. Some coordination will be required with medical providers for 2nd level reviews and evaluating against prior authorizations and UB claims. If a candidate has a fingerprint clearance card, that may help expedite the start date. The temp will need a computer which the client can set up remote desktop access. The role does not currently allow for Overtime but could be approved as the client has need. For the questions above, HRD stated: We will conduct a fingerprint background check and Knowledge Services is aware of the requirement to have all candidates printed and results on hand with HRD before and contractor is onboarded.
Major duties and responsibilities include but are not limited to:
Performs medical claims review/adjudication using claims industry standards. Determines if a claim meets emergency criteria, medical necessity, and/or correct revenue code/CPT/HCPC coding. Also determines if the level of care and length of stay is appropriate for the client recipient.
Prepares reports and analyzes savings and trends. Interacts with other departments/providers as needed.
Performs special projects including but not limited to research projects.
Knowledge:
Medical nursing practice, medical case management protocols, quality management and utilization review protocols as related to all populations including Maternal and Child Health services, preventive health, family planning, sterilization, and pregnancy termination, EPSDT, acute, LTC, chronic long-term elderly and physical disabled, developmentally disabled, behavioral/mental health, and Tribal
Healthcare delivery system nationally and locally
Managed care processes
Acute nursing processes including assessment, planning, intervention, and evaluation
InterQual Criteria
CCI
Coding: CPT, HCPCS, ICD-9
Medical Claims Review
Statistical analysis
Computer data retrieval and input
Interpretation of governmental client
Client Rules and Regulations
Code of Federal Regulations
Requirements:
Active RN License in AZ
Skills:
Organizational skills that result in prioritization of multiple tasks
Interpretation of rules, laws and client policy pertaining to the client program
Good written and communication skills
Computer skills
Utilization Review skills
Medical Claims Review skills
Producing work products with limited supervision
Effectively collaborating with people in positions of all levels
Research and analysis
Team player and can work independently
Abilities:
Interpret and apply medical and claims policies
Read and interpret medical documentation
Evaluate medical documentation for emergency criteria, medical necessity, correct CPT coding
Determine appropriate hospital levels of care and lengths of stay
Respond to inquiries for UR/CPT coding decisions
Maintain data for monthly reports
Work independently with minimal supervision
Ability to work Virtual Office
Experience Requirements:
High school Diploma
Minimum: Possession of a current license to practice as a registered nurse in AZ and experience in health care delivery systems.
Preferred: Experience in concurrent and retrospective review; CCI, lnterQual, HCPCS and CPT Coding; managed care medical review experience. Certification in CPT Coding is a plus.
Notes:
Schedule:
8:*00am- 5:*00pm 40hrs per week, (M-F, no weekends unless OT is requested).
Primarily remote, however candidates may need to go onsite. Candidate may go onsite for training 1-2 times for training once starting position.
Job Type: Contract
Pay: $30.00 - $34.00 per hour
Expected hours: 40 per week
Schedule:
- 8 hour shift
Ability to Commute:
- Phoenix, AZ 85034 (Preferred)
Ability to Relocate:
- Phoenix, AZ 85034: Relocate before starting work (Preferred)
Work Location: Hybrid remote in Phoenix, AZ 85034
Salary : $30 - $34
