Medical Review Nurse III - Suspended Claims

Recruitment #211008-UNCY-312

Introduction

 

POSITION PURPOSE: 
Act as the clinical reviewer of the highest and most complex cases (through claims reviews.) This could include, but is not limited to, complex Caesarean Section (C/S), manual pricing, and Genetic testing claims. These are reviewed in a retrospective claim scenario. The main medical review nurse lll responsibilities are medical necessity reviews in the MMIS system 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.

PRINCIPLE ACTIVITIES
*Reviews all documents required, including provider documentation, and complete the processing of suspended and/or denied claims.
*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.
*Interfaces directly with OHCA physicians on documentation and/or claims processing issues.
*Using clinical experience, acts as a resource to OHCA staff on claim resolution, system and/or policy-related issues.
*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). Ensures that these materials are in accordance with existing State and Federal regulations.
*Schedules, arranges and participates in internal and external meetings.
*Other duties as assigned.

EDUCATION AND/OR EXPERIENCE
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.

PREFERENCE MAY BE GIVEN TO CANDIDATES WITH:
*Advanced health related education (e.g., BSN, MSN)
*Medicaid experience
*Managed care experience
*Coding experience
*Utilization experience
*Policy development experience
*Quality assurance/improvement experience

Accommodation Statement:
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.

Conclusion

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