Medical Management - Medical Review Examiner Nurse 145-2051

JOB SUMMARY:
The Medical Review Examiner Nurse is responsible for auditing provider and facility claims. Identifying issues related to and/or participates in various projects aimed at identifying areas of non-compliance and/or potential fraud, waste and abuse, as it relates to provider billing practices.

KEY RESPONSIBILITIES:

• Review claims by requesting medical records and other documents to evaluate for clinical appropriateness, coding compliance and validity of charges. Document ineligible charges and provide communications internally for claims processing and externally to providers.
• Provide review of complex claims for further research meeting the MRE “pend” criteria. Collaborate with Medical Director and/or other departments (and resources) to make claim determinations.
• Maintain tracking database including self-audit for quality control. Compile and analyze data and prepare routine reports as assigned. Identify trends and formulate recommendations based on findings. Suggest opportunities for special study.
• Serve as an internal resource to provider services, contracting, claims, medical management, configuration, and appeals & grievances. Provide guidance as it relates to clinical appropriateness of services. Participate in provider education upon request.
• Maintain files of MRE records. Participate in special projects and audits as assigned.

QUALIFICATIONS:

• Extensive knowledge of ICD-9, ICD-10, HCPS, CPT-4 codes.
• Able to work independently and meet stringent deadlines.
• Successful completion of Health Care Sanctions background check.
• Proficiency in claims processing software and Microsoft applications.
• Possess strong oral and written communication skills.

EDUCATION/EXPERIENCE:

• Current, active, unrestrictive license to practice as Registered Nurse (RN) or Licensed Practical Nurse (LPN) in the State of Oklahoma. Associates Degree required; Bachelor’s Degree preferred.
• Five years of work experience in hospital, clinic or health plan clinical operations (for example utilization review, quality improvement, clinical claims review).
• Experience or familiarity with state and federal regulations governing healthcare preferred.

CommunityCare is an equal opportunity at will employer and does not discriminate against any employee or applicant for employment because of age, race, religion, color, disability, sex, sexual orientation or national origin