Job Description:
Responsible for accurate and timely processing of healthcare claim service request and processing claims
Reviews, evaluates the service request as per SOP
Familiar with Medical Policy, Familiar with Clinical service requests, correspondence inquiries and image review
Forward the cases to appropriate teams, post the in-scope activities have been completed as per SOP (Standard operating Procedure)
Prep medical records for clinical review
End to end processing and resolution of clinical claims and correspondence
Understand/interpret medical terminology including clinical notes and reports
Able to review medical policies and determine the appropriate claim processing or clinical review process decisions (pay, request additional records, refer for clinical review)
Review and determine pricing for clinical claims in accordance with negotiated pricing agreements
Adept knowledge of verifying member benefits, eligibility verification and medical necessity determination
To apply clinical judgement in lines of applicable guidelines while they provide post service Medical Necessity Determination (MND) reviews for Claim Policy business area led by reputed US Payer organization/s
To work in collaboration with Medical Directors to deliver top quality medical necessity determination services to clients
Basic Qualifications
High School Diploma or GED Equivalent
Must have 2 years clinical experience , but also experience with running trainings ( a seasoned RN would be ideal
Fully Bilingual- English and Spanish- (All work performed will be in English)
Job Type: Permanent
Pay: $21.00 per hour
Benefits:
401(k)
Dental insurance
Health insurance
Paid time off
Vision insurance
Experience:
Clinical setting RN: 2 years (Required)
Language:
English (Required)
Work Location: On the road