RN, Claims Reviewer – Full Time – Hourly – 100% Remote CA
Description The Registered Nurse Claims Reviewer will be responsible for review of clinical and claims data to ensure accuracy in hospital billing and compliance with healthcare regulations. Professional Duties • Inpatient admissions review: Analyze all inpatient admissions to differentiate between observation and inpatient statuses. Assess clinical significance to ensure hospital billing aligns with organizational claims. • Electric Health Record (EHR) Correlation: Provide daily updates correlating clinical order in the EH, utilizing Nextgen and EZCap systems. • Diagnosis verification: Review admission diagnosis to confirm accuracy based on clinical presentation, documentation and treatment. • Air ambulance review: Evaluate air transportation cases against healthcare clinical requirements and provider recommendations for compliance payment. • Acute respiratory failure assessment: Review post hospital patients diagnosed with acute respiratory failure to validate accuracy based on hospital treatment protocols and patient trajectory. • Sepsis diagnosis review: Review post hospital patient records that were diagnosed with acute sepsis to validate accuracy based on hospital treatment protocols. • Perform other duties as assigned. • Be knowledgeable about your job so that you can serve others effectively • Do your share. Do what you say you will do and take action, follow through. Be willing to pitch in and help • Be an active listener (make eye contact, validate) • Be accountable for your work Qualifications • Associates or Bachelors degree required. • Current California RN License required. • A minimum of seven (7) years of clinical nursing experience required. • Proficient with computer and word processing programs. Current knowledge of medical billing, coding and healthcare regulations. • Ability to effectively communicate with all levels of the organization, patients, patient family members, providers and others. • Ability to work independently, function under pressure and multi-task at any given time. • A commitment to precision, diligence, and thoroughness in all aspects of their work. • At the discretion of DOHC/FHC Management, this position has the potential to be a full or hybrid telecommuting position. Physical Demands Type Description Sitting Approximately 90% of day. Standing Approximately > 5% of day. Walking Approximately > 5% of day. Lifting 0 - 20 lbs. (equipment, supplies) approximately >10% of day. Bending Approximately >10% of day. Kneeling