CLINICAL REVIEW SPECIALIST
- Remote – Wisconsin
- Remote – Alaska
- Remote – Alabama
- Remote – Maryland
- Remote – Maine
- Remote – Louisiana
- Remote – Kentucky
- Remote – Kansas
- Remote – Iowa
- Remote – Indiana
- Remote – Wyoming
- Remote – Oregon
- Remote – New Hampshire
- Remote – Nevada
- Remote – West Virginia
- Remote – Nebraska
- Remote – Washington
- Remote – Montana
- Remote – Virginia
- Remote – Missouri
- Remote – Vermont
- Remote – Mississippi
- Remote – Utah
- Remote – Texas
- Remote – Tennessee
- Remote – Michigan
- Remote – Ohio
- Remote – Massachusetts
- Remote – South Dakota
- Remote – South Carolina
- Remote – North Dakota
- Remote – Rhode Island
- Remote – North Carolina
- Remote – Pennsylvania
- Remote – New York
- Remote – New Mexico
- Remote – New Jersey
- Remote – Illinois
- Remote – Idaho
- Remote – Hawaii
- Remote – Georgia
- Remote – Florida
- Remote – Delaware
- Remote – DC
- Remote – Connecticut
- Remote – Colorado
- Remote – Oklahoma
- Remote – California
- Remote – Arkansas
- Remote – Arizona
- Full time
Transforming the future of healthcare isn’t something we take lightly. It takes teams of the best and the brightest, working together to make an impact.
As one of the largest healthcare technology companies in the U.S., we are a catalyst to accelerate the journey toward improved lives and healthier communities.
Here at Change Healthcare, we’re using our influence to drive positive changes across the industry, and we want motivated and passionate people like you to help us continue to bring new and innovative ideas to life.
If you’re ready to embrace your passion and do what you love with a company that’s committed to supporting your future, then you belong at Change Healthcare.
Pursue purpose. Champion innovation. Earn trust. Be agile. Include all.
Empower Your Future. Make a Difference.
The Clinical Review Nurse is responsible for reviewing and researching post service claims for aberrant billing patterns, through review of the medical record documentation. This position also provides clinical expertise to the Insight Analysts for overall case management.
- Includes, but are not limited to:
- Conducts clinical reviews of medical records and supporting documentation against submitted claims, for individual provider, facility and laboratory claims, to determine coding and billing accuracy for all products.
- Processes and/or reviews claims in a timely manner utilizing client specific coding and billing requirements that meets or exceeds production and quality goals.
- Documents clinical review findings within case tracking system and maintains thorough and objective documentation of findings.
- Serves as a clinical resource and provides clinical expertise, and clinical guidance to entire Insight Record Review team for case management.
- Monitors, tracks and reports on all case work.
- Interfaces with customers by telephone or correspondence to answer questions and resolve issues relative to review criteria and processes.
- Consults with physicians and other clinical resources when necessary.
- Communicates determinations verbally and/or in writing to appropriate business department as required by department internal workflow policies.
- Participates in process improvement activities and encourages ownership of and group participation in improvement initiatives.
- Identifies and recommends opportunities for cost savings and improving outcomes.
- The position responsibilities outlined above are in no way to be construed as all-encompassing. Other duties and responsibilities, may be required and/or assigned as necessary.
Minimum Requirements (Required):
Critical Skills (Required):
Additional Knowledge and Skills (Preferred / Not Required):
General Office Demands
Join our team today where we are creating a better coordinated, increasingly collaborative, and more efficient healthcare system!
Equal Opportunity/Affirmative Action Commitment
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.
- RN required, with related clinical review experience
- Coding experience a plus
- Minimum of 5 years clinical experience
- Local-Remote/Work from home
- Knowledge of medical terminology, CPT-4, and HCPCS coding
- Working knowledge of coordination of benefits and medical claims processing
- Strong problem-solving skills
- Excellent organizational, interpersonal and communication skills
- Ability to use MS Office to include Excel
- Ability to work in a fast-paced environment
- Must be flexible and have the ability to adapt in a changing environment
- Knowledge of ICD-9 and ICD-10 a plus
- Acute sense of professionalism and confidentiality
- RN required