Medical Review Nurse - CA RN

About SCAN

SCAN Group is a not-for-profit organization dedicated to tackling the most pressing issues facing older adults in the United States. SCAN Group is the sole corporate member of SCAN Health Plan, one of the nation’s leading not-for-profit Medicare Advantage plans, serving more than 280,000 members in California, Arizona, Nevada, Texas and New Mexico. SCAN has been a mission-driven organization dedicated to keeping seniors healthy and independent for more than 45 years and is known throughout the healthcare industry and nationally as a leading expert in senior healthcare. SCAN employees are a group of talented, passionate professionals who are committed to supporting older adults on their aging journey, while also innovating healthcare for seniors everywhere. Employees are provided in-depth training and access to state-of-the-art tools necessary to do their jobs, as well as development and growth opportunities. SCAN takes great pride in recognizing our team members as experts in their fields and rewarding them for their efforts. If you are interested in becoming part of an organization that is innovating senior healthcare visit www.thescangroup.org, www.scanhealthplan.com, or follow us on LinkedIn, Facebook, and Twitter.

The Job

Provide clinical review of medical claims and post service appeals. Facilitate appropriate investigation of issues and management of medical services, claims-billed charges, and benefit administration while maintaining SCAN timeframe standards.

You Will

Review and analyze pre and post payment of complex health care claims from a medical perspective.

Perform audits/reviews of medical claims per established criteria, identify need for medical record review, necessary documentation to support decision making process regarding appropriateness of claim, billed charges, benefit coverage.

Provide guidance to other staff members and accurately interpret and apply broad Centers for Medicare and Medicaid Services (CMS) guidelines to specific and highly variable situations.

Conduct review of claims data and medical records to make clinical decisions on the coverage, medical necessity, utilization and appropriateness of care per national and local policies as well as accepted medical standards of care.

Process workload and complete project work in the appropriate computer system(s).

Route identified clinical and /or risk issues to appropriate personnel e.g. Medical Director, Quality of Care (QOC) Nurse, Medical Management Specialist, Member Services, etc.

Review/prepare potential claims denials in conjunction with Medical Director.

Collaborate with Medical Director pursuant to adjudication of claims and post service appeals.

Participate in special projects/workgroups/committees (e.g., interdisciplinary workgroups, report analysis, Independent Review entity (IRE) etc.) as assigned and as necessary and appropriate.

Contribute to team effort by accomplishing related results as needed.

Actively supports the achievement of SCAN’s Vision and Goals

Your Qualifications

Completed Nursing Degree or Diploma. CA RN with specific experience & work history.

Current and active CA RN License in good standing required.

Certified Professional Coder preferred.

3-5 years of experience in clinical decision making, relative to Medicare patients.

Experience using claims processing system.

Knowledge of Medicare and Medi-Cal rules and regulations, including ability to research coverage guidelines/criteria.

Background and/or training in use of nationally recognized, standardized clinical decision support criteria, as applicable to ensure consistency in clinical review. (e.g. Milliman Care Guidelines).

Experience/knowledge in the appeals/claims processing procedures in Managed Care or similar experience.

Working knowledge of the Managed Care regulatory agencies and the applicable laws and regulations.

Strong oral, written and analytical skills.

Ability to work independently and in a team environment.

What's in it for you?

• Base salary range: $38.61 to $61.78 / hour
• Remote work mode
• An annual employee bonus program
• Robust Wellness Program
• Generous paid-time-off (PTO)
• Eleven paid holidays per year, plus 1 additional floating holiday, plus 1 birthday holiday
• Excellent 401(k) Retirement Saving Plan with employer match
• Robust employee recognition program
• Tuition reimbursement
• An opportunity to become part of a team that makes a difference to our members and our community every day!

We're always looking for talented people to join our team!  Qualified applicants are encouraged to apply now!

At SCAN we believe that it is our business to improve the state of our world. Each of us has a responsibility to drive Equality in our communities and workplaces. We are committed to creating a workforce that reflects our community through inclusive programs and initiatives such as equal pay, employee resource groups, inclusive benefits, and more.

SCAN is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.

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