Medical Review Nurse III

Recruitment #200210-UNCY-35



Act as the clinical reviewer of the highest and most complex cases (either through claims or prior authorization workflow (pawf) reviews.) This could include, but is not limited to, complex Caesarean Section (C/S), manual pricing, Genetic Testing claims  to complex  prior authorizations, such as, Transplants, Bariatric cases or other types of complex PA’s. These can be reviewed either in a prospective pawf case or retrospective claim scenario. The main MAR lll responsibilities are medical necessity reviews in either the MMIS and/or prior authorization workflow systems and make recommendations based on current clinical and coding guidelines.  Make recommendations for changes based on current clinical industry standards.  Evaluate claim processing through MMIS and ClaimCheck to identify areas of potential payment errors.  To make recommendations for system and/or policy changes as indicated.

*Reviews all documents required, including provider documentation, and complete the processing of suspended and/or denied claims.
*Review, research, and facilitate prior authorization of medically-necessary medical services that require a prior authorization. Facilitate authorizations by following established polices and guidelines.
*Coordinates the development of new policy and/or changes to existing policy and makes recommendations based on current clinical guidelines.
*Evaluates claim processing through MMIS and ClaimCheck to identify areas of potential payment errors. Makes recommendations for system and/or policy changes as indicated.
*Collaborates with medical staff to incorporate clinical standards and decision-making into the existing Medicaid program and subsystems.
*Research and respond to provider, customer service, provider representatives and other internal OHCA staff inquiries regarding coding/clinical claims editing and to resolve any medical authorization issues.
*Interfaces directly with OHCA physicians on documentation and/or claims processing/prior authorization issues.
*Collaborate with OHCA Care Management regarding members’ care to ensure coordination of overall Medicaid Care Management efforts.
*Using clinical experience, acts as a resource to OHCA staff on claim resolution, system and/or policy-related issues. Act as medical authorization resource for OHCA personnel as well, regarding issues related to medical prior authorization.
*Makes recommendations and assists in the development of new material and revisions to existing material for various OHCA publications and documents (e.g., SoonerCare Provider Manual, Billing and Procedure Manual, provider letters, provider contracts, etc.). Ensures that these materials are in accordance with existing State and Federal regulations.
*Provides training and assistance with interpretation of existing policies, development of new policies, and claims processing issues. Interfaces with public, legislative and health care stakeholders and disseminates statistical, educational, and informational materials, as directed.
*Schedules, arranges and participates in internal and external meetings.
*Other duties as assigned.

Current/Valid RN license AND 3 years of clinical experience and experience in health care monitoring (e.g., quality assurance, surveillance and utilization review, auditing, health policy), clinical coding, and reimbursement, clinical review of claims and claims auditing AND Experience using database applications AND Certified Professional Coder (CPC) certification preferred.

*Bachelor’s degree in Nursing
*Medicaid experience
*Managed care experience
*Coding experience
*Utilization experience
*Policy development experience
*Quality assurance/improvement experience
*Advanced health related education (e.g., MSN)

The Oklahoma Health Care Authority complies with applicable Federal civil rights laws and does not discriminate.  All qualified applicants will receive consideration for employment without regard to race, color, sex, religion, disability, age, national origin, or genetic information. If a reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact the Civil Rights Coordinator at 405-522-7335.



Veteran’s preference points apply only for initial appointment in the classified service.