Job Description

The Company

This private equity sponsored organization is the largest and fastest-growing Third Party Administrator (TPA) in the United States. With over a half Century of benefit plan administration experience, 1,500+ team members, and 45 locations across the United States, this organization provides the technologies, services, systems, and support methodology to self-funded benefit plans to help meet the demands of increasingly complex and rapidly evolving regulatory changes in a cost-effective manner.

The Position (Temp / Remote / Part-Time)

Performs medical review and investigation of claims, including complex claims, to determine medical necessity and appropriateness, in accordance with Company guidelines, client needs, and legislative requirements. 

Hours: Flexible, 25-30 hours per week. Flex-time available. 

Key duties include: 

  • Review claims to ensure the services are not experimental and that the diagnosis meets the treatment recommended.
  • Determine medical necessity and decide if claim should be sent for additional review by an outside vendor.  
  • Provide customer service by responding to and documenting telephone and/or written inquiries.
  • Consistently meet established performance standards, including quantity and quality of clinical claims reviews.
  • Maintain current knowledge of assigned Plan(s) and effectively apply knowledge in the payment of claims, customer service, and all other job functions.
  • Performs Clinical reviews on medical necessity and billing support issues in relation to appeals, arbitration and litigation utilizing industry recognized guidelines such as CMS. 
  • Performs audits on medical necessity and billing support decisions made by outside vendors. 
  • Become proficient in Claims operating system and all electronic systems of record
  • Acts as clinical resource to the claims and customer service department.

The Successful Candidate

The successful candidate will demonstrate the knowledge, skills, and abilities necessary to perform the essential functions of this position. This includes, but is not limited to the following competencies:

  • Registered Nurse RN License.
  • Review and assess medical necessity of services (minimum 2-5 years of experience)
  • 2+ years experience in health care claims administration, with a variety of plan designs.  
  • Knowledge of medical terminology CPT, ICD-9 diagnosis codes required. 
  • Experience working for an Insurance company, TPA, or related health care organization. 
  • Familiarity of the TPA business and Taft-Hartley Welfare Funds preferred.
  • Possess a strong work ethic and team player mentality.
  • Highly developed sense of integrity and commitment to customer satisfaction.
  • Ability to communicate clearly and professionally, both verbally and in writing.
  • Ability to function independently within established guidelines.
  • Solid organization skills with strong detail orientation and listening skills.
  • Strong decision making, research and analytical abilities.
  • Ability to read, analyze, and interpret general business materials, technical procedures, benefit plans and regulations.
  • Ability to calculate figures and amounts such as discounts, interest, proportions, and percentages.
  • Ability to type 35 WPM; proficient PC skills, including MS Word and Excel.
  • Bachelor's degree in a related field, or equivalent combination of education and work experience.

Compensation 

The Nurse Reviewer will be a skilled member of the Claims team. As such, they will receive a competitive compensation package, to include:

  • Competitive compensation.
  • Health benefits.

Application Instructions

Please click on the link below to apply for this position. A new window will open and direct you to apply at our corporate careers page. We look forward to hearing from you!

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