Responsibilities Provide timely review and determination of medical claims, including prior authorization, appeals, and/or any other type of medical claims Analyze medical records related to the case file Review and interpret Local Coverage Determination (LCD), National Coverage Determination (NCD) policies, and other federal regulations Apply appropriate regulatory citations, including health plan policies, NCD/LCDs, and/or other regulations to each claim as it relates to the item or issue Formulate a narrative decision citing relevant regulatory back‑up documentation contained within the medical record Adjudicate claim based on the regulations and documentation contained within the medical record Attend FHAS and/or client Lunch & Learn sessions and/or general training sessions on site as needed Complete IRR surveys in a timely fashion as required by the prime contractor Maintain a 97% or higher quality score Qualifications Must possess a current, unrestricted State license as a Registered Nurse (RN) as required by contract(s) 1+ years clinical experience required; coding, utilization, and/or medical chart review preferred Professional Coding Certification preferred Detailed knowledge of Medicare regulations and guidelines, policies, and payer reimbursements preferred Knowledge of CPT, HCPCS, ICD‑10 codes and coding guidelines Ability to identify Medicare billing and payment irregularities Excellent analytical, written and oral communication skills, and ability to support review findings Ethical, self‑motivated and results‑oriented team player Strong analytical, verbal and written communication skills Outstanding people skills and ability to effectively review findings/results with management Proficient with PC and related software programs Excellent organizational skills Must be a team player Limited travel may be required Physical Requirements Must be able to remain in a stationary position 95% of the time Constantly operate a computer and other office equipment such as telephone Regular and predictable attendance is essential for this position #J-18808-Ljbffr
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