Job Description

Under the general direction of the Medical Director, the Claims Review Nurse is responsible for reviewing medical bills and documentation using good judgment to make decisions regarding appropriate billing practices and communicating decisions to all stakeholders both internal and external.  

Position is responsible for remaining informed on billing and payment legislation and complying with all regulations related to review and payment.  Claims Review Nurse will at all times maintain strict confidentiality on behalf of RMG/ HPN members, providers and other stakeholders.

Qualifications

Education and / or Experience:

• Must have an active nursing license LVN in the state of California with no restrictions and a minimum of 1 year of patient care experience in a hospital setting.
• Must be able to perform with minimum supervision.
• Full working knowledge of medical group/managed care environment including capitation, TPL, COB, PPO, and POS.
• Knowledge of DRG Grouper, CPT-4, HCPCS, Revenue and ICD-9 coding.
• Extensive knowledge of Medicare, and Medi-Cal.Knowledge of contracts and contractual interpretations for payment and benefit issues.
• Strong knowledge of Microsoft Windows environment.
• Excellent written and verbal communication skills.
• Strong organizational and problem solving skills.

About the Hospital

As one of the largest physician-led networks in Southern California, we have thousands of physicians and hundreds of hospitals committed to providing quality healthcare to all of the communities we serve.

Every day, our employees are inspired to make a difference in the lives of others as well as transform their own experiences to achieve a higher sense of fulfillment. Our employees become a part of an extraordinary team of people dedicated to health, wellness, and happiness for themselves and others. There is no greater reward than contributing to a positive work environment where compassion, understanding, care and attention are encouraged and valued.