Description
The Registered Nurse Claims Reviewer will be responsible for review of clinical and claims data to ensure accuracy in hospital billing and compliance with healthcare regulations.
Professional Duties
• Inpatient admissions review: Analyze all inpatient admissions to differentiate between observation and inpatient statuses. Assess clinical significance to ensure hospital billing aligns with organizational claims.
• Electric Health Record (EHR) Correlation: Provide daily updates correlating clinical order in the EH, utilizing Nextgen and EZCap systems.
• Diagnosis verification: Review admission diagnosis to confirm accuracy based on clinical presentation, documentation and treatment.
• Air ambulance review: Evaluate air transportation cases against healthcare clinical requirements and provider recommendations for compliance payment.
• Acute respiratory failure assessment: Review post hospital patients diagnosed with acute respiratory failure to validate accuracy based on hospital treatment protocols and patient trajectory.
• Sepsis diagnosis review: Review post hospital patient records that were diagnosed with acute sepsis to validate accuracy based on hospital treatment protocols.
• Perform other duties as assigned.
• Be knowledgeable about your job so that you can serve others effectively
• Do your share. Do what you say you will do and take action, follow through. Be willing to pitch in and help
• Be an active listener (make eye contact, validate)
• Be accountable for your work
Qualifications
• Associates or Bachelors degree required.
• Current California RN License required.
• A minimum of seven (7) years of clinical nursing experience required.
• Proficient with computer and word processing programs. Current knowledge of medical billing, coding and healthcare regulations.
• Ability to effectively communicate with all levels of the organization, patients, patient family members, providers and others.
• Ability to work independently, function under pressure and multi-task at any given time.
• A commitment to precision, diligence, and thoroughness in all aspects of their work.
• At the discretion of DOHC/FHC Management, this position has the potential to be a full or hybrid telecommuting position.
Physical Demands
Type
Description
Sitting
Approximately 90% of day.
Standing
Approximately > 5% of day.
Walking
Approximately > 5% of day.
Lifting
0 - 20 lbs. (equipment, supplies) approximately >10% of day.
Bending
Approximately >10% of day. Kneeling <20%.
Hearing/Visual Acuity
Adequate for use with computers, telephone and/or Blackberry. Approximately 100% of day.
Computer
Highly technical work environment. Must be able to work minimum of 7 hours a day using keyboard, mouse and monitor.
Reaching
Above head 75 degrees approximately 10% of day.
Hand grip dexterity
Approximately 70% of day.
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Apply Now