Registered Nurse Coder - DRG Reviewer (Remote)

About the position

Responsibilities

• Perform in-depth analysis, clinical review, and resolution of provider pre and post payment claims related to medical coverage guidelines and community standards.
• Review and prepare internal audit cases for Medical Directors.
• Identify, research, process, resolve, and respond to Senior Medical Director inquiries primarily through written/verbal communication.
• Analyze medical records and apply medical necessity criteria and benefit plan requirements to determine the appropriateness of billing and charges.
• Maintain complete and accurate records per BCBSAZ policy.
• Meet quality, quantity, and timeliness standards to achieve individual and department performance goals as defined within the department guidelines.
• Consult and coordinate with various internal departments, external plans, providers, businesses, and government agencies to obtain information and ensure resolution of large scale projects.
• Participate in continuing education and current developments in the fields of medicine and managed care.
• Maintain productivity and accuracy goals based on regulatory requirements, accreditation standards, and service level agreements.
• Demonstrate ability to acquire specialized knowledge to complete all types of projects for all lines of business.

Requirements

• Experience in clinical and health insurance or other healthcare related field (1-8 years depending on level).
• Managed care experience with a focus on Utilization Management (UM), Prior Authorization (PA), Claims, Medical Review, Case Management, and/or Medical Appeals and Grievances (MAG) (1-3 years depending on level).
• Associate's Degree in a healthcare field of study or Nursing Diploma.
• Active, current, and unrestricted license to practice in the State of Arizona as a Registered Nurse (RN).
• Certified Medical Coder.

Nice-to-haves

• Experience in clinical and health insurance or other healthcare related field (3-9 years depending on level).
• Managed care experience with a focus on Utilization Management (UM), Prior Authorization (PA), Claims, Medical Review, Case Management, and/or Medical Appeals and Grievances (MAG) (2-5 years depending on level).
• Bachelor's Degree in Nursing or related field of study.
• Master's Degree in Nursing or related field of study.