Claims Review RN

Get To Know Us! WebTPA, a GuideWell Company, is a healthcare third-party administrator with over 30+ years of experience building unique benefit solutions and managing customized health plans. What is your impact? The Claims Review RN provides appropriate and comprehensive coding and claims review, while partnering with the claims and clinical department for appropriate use of services and benefits. What Will You Be Doing: AUDITS CLAIMS FOR CODING AND UTILIZATION ACCURACY: Using coding and claims expertise, review claims for appropriate coding/utilization. Reviews selected claims and provided clinical feedback to the Claims Manager/Director as requested. Conducts medical record review to determine medical necessity of requested services. Determines plan level benefits and requirements and appropriate designation under each client's SPD. Assesses the clinical status of the claim and provides feedback designation to appropriate claims/clinical requestor. Ensures appropriate utilization of Medical Director Review/IRO/Independent Medical Review. Reviews selected cases for medical pre-determination and makes recommendations based on clinical criteria/evidence-based medicine. Works with Care Management team to ensure appropriate clinical review/input. Ensures accurate and timely reporting as deemed appropriate by each client and department. UTILIZATION OPTIMIZATION: Establishes identification of services, resources, providers, and facilities that could best serve clientele in a timely and cost effective manner in an effort to obtain optimum value for the client and reimbursement source. Evaluates the cost effectiveness of the elected plan, pre-implementation, and post implementation. This outcome measurement will be used in determining the effective results and in establishing future patient centered care plans. Interprets individual health plans and authorizes/coordinates care in accordance with plan provisions. REVIEW AND RESEARCH MEMBER/PROVIDER APPEALS: Reviews appeal and medical documentation. Reviews appeal to ensure proper coding and assignment to appropriate workstream. Accesses claims database to review how claim was originally processed. Leads clinical research and processing of appeals in accordance with Employee Retirement Income Security Act (ERISA), Health Insurance Portability and Accountability Act (HIPAA), and corporate/departmental standards, Forwards appeal to appropriate IRO agency with supporting documentation when required. Works with business partners across the organization, as needed, to gather data as input for final determination. Follows regulatory requirements as appropriate and corporate values, policies and procedures. Creates appropriate statement within final document to provider that supports final determination. Qualifications: 5+ years related nursing work experience Related Bachelor’s degree or additional related equivalent work experience A graduate of an accredited school of nursing RN - Registered Nurse - State Licensure Previous claims review/coding experience Professional background in clinical nursing, patient assessment Prior experience in managed care/claims review/coding review, specifically in the self-funded arena Knowledgeable in medical terminology, reasonable and necessary treatment plans, delivery quality health care services and cost containment practices. Coding certification preferred What We Can Offer YOU! To support your wellbeing, comprehensive benefits are offered. As a WebTPA employee, you will have access to: Medical, dental, vision, life and global travel health insurance Income protection benefits: life insurance, Short- and long-term disability programs Leave programs to support personal circumstances Retirement Savings Plan includes employer contribution and employer match Paid time off, volunteer time off, and 11 holidays Additional voluntary benefits available and a comprehensive wellness program Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for interns and part-time employees may differ. General Physical Demands Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally. We are an Equal Employment Opportunity employer committed to cultivating a work experience where everyone feels like they belong and can perform at their best in pursuit of our mission. All qualified applicants will receive consideration for employment.