Nursing, Pharmacy, & Health Services - Utilization Management
Company: ICONMA, LLC
Location: Rancho Cordova
Posted on: June 19, 2022
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Job Description:
Ensures accurate and timely clinical review of claims requiring
review.
The Post Service Clinical Review RN performs claim reviews
utilizing Client evidenced based guidelines, medical policies, and
nationally recognized clinical criteria.
The successful RN candidate will review post service clinical claim
review and provider appeals for medical necessity, coding accuracy
and medical policy compliance. Clinical judgment and detailed
knowledge of benefit plans used to complete review decisions is
required.
The RN prepares and submits clinical case reviews to the Medical
Director (MD) for MD collaboration and medical necessity
determination, if needed.
RN triages and prioritizes their caseload to meet required
regulatory turn-around times.
The RN communicates determinations to the members and providers in
compliance with state, federal and accreditation requirements.
The RN ensures the coding and diagnosis reviewed with the appeals
submitted match the services being requested/billed for the
member.
The RN will refer members for Case Management as needs are
identified.
Requirements
Bachelor of Science in Nursing or advanced degree preferred and 3
years of prior relevant experience.
Knowledge of CPT, ICD-10, HCPCS and billing practices.
Demonstrate the ability to act independently using sound clinical
judgement.
Demonstrate strong verbal and communication skills.
Proficient skills with Microsoft Office Suite.
RN license.
As an equal opportunity employer, ICONMA prides itself on creating
an employment environment that supports and encourages the
abilities of all persons regardless of race, color, gender, age,
sexual orientation, citizenship, or disability
Olivia Ojiaku
M: (248) 515-6856
Keywords: ICONMA, LLC, Rancho Cordova , Nursing, Pharmacy, & Health Services - Utilization Management, Executive , Rancho Cordova, California
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