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Conduct in-depth clinical and claims reviews using benefit plans, medical policies, claims systems, member enrollment information, provider contracts, and other relevant resources.
Analyze claims and determine appropriate resolution in accordance with department policies and applicable state and federal requirements.
Identify and monitor claims trends that may indicate educational opportunities, policy or guideline updates, referrals, or potential fraud, waste, and abuse.
1–2 years of related medical coding, auditing, or clinical experience.
Associate degree, post-high-school nursing diploma, LPN certification from an approved program, or an equivalent combination of education and experience. CPC, CCS, or CPMA certification required within 6 months of starting.2+ years of medical coding or auditing experience.
2+ years of experience in utilization review, quality assurance, or the health insurance industry.
Bachelor's degree in Nursing or a related field.
