Job Title: Registered Nurse
Location: Aguadilla, Puerto Rico
?Must have Puerto Rico Registered Nurse License with Any US Compact state license
Compact US States: WA, ID, MT, WY, UT, AZ, NM, CO, ND, SD, NE, KS, OK, TX, LA, AR, MO, IA, WI, MS, IN, KY, TN, AL, GA, FL, SC, NC, VA, WV, VT, NH, ME
In this role, you will be responsible for accurate and timely processing of healthcare claim service request and processing of claims using your medical knowledge to process according to a workflow that requires the review and evaluation of the service request as per SOP.
For this role, you must be familiar with Medical Policy, Familiar with Clinical service requests, correspondence inquiries and image reviews and MUST have the Florida endorsement.
Job responsibilities:
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
At least 2 years of experience relating to the job description
Preferred Qualifications
Fully Bilingual- English and Spanish- (All work performed will be in English)
Current Puerto Rico Registered Nurse valid license and a valid Florida or any US state endorsement
Intermediate to advanced knowledge in using MS Office and ability to learn and use various computer software
Past experience in an office/clerical setting in the medical field
Experience in any claim adjudication platform
Certification in medical coding (CPT, ICD-10
Exposure to Healthcare Claims products (Indemnity, PPO, POS/DA, EPO, HMO)
Prefer knowledge of Workman's Compensation, Medicare, COB, no fault
Prior claims experience in medical coding, case management, cost containment review, medical claim management will be preferred
Exposure to anti-fraud initiatives in clinical area
Awareness of clinical practice guidelines used by health plans to develop medical policy
Possess eye for details
Knowledge of Microsoft Office Products
Team Player, Analytical, Written and Verbal Communication Skills, Interpersonal Skills and Positive Attitude
Note
: Applicants for employment in the U.S. must possess work authorization which does not require sponsorship by the employer for a visa (H1B or otherwise).
The job entails sitting as well as working at a computer for extended periods of time. Should be able to communicate by telephone, email or face to face.
Work Model:
This role is onsite 5 days per week in the office in Aguadilla.
Job Type: Full-time
Pay: $20.00 - $21.00 per hour
Expected hours: 40 per week
Benefits:
Dental insurance
Health insurance
Life insurance
Vision insurance
Experience:
Nursing: 2 years (Required)
License/Certification:
Florida endorsement OR any US Compact state license (Required)
Ability to Relocate:
Aguadilla, PR: Relocate before starting work (Required)
Work Location: In person