Are you passionate about making a difference? The World Trade Center (WTC) Health Program provides support to those impacted by 9/11. This position for a medical claims review nurse on the World Trade Center (WTC) Health Program will have a direct impact on members of the program. The nurse will be responsible for reviewing claims that pend to Medical Review to ensure all services are medically necessary as well as analyzing and responding to provider appeals.
Responsibilities:
o Analyzing claims issues for claims pended to Medical Review
o Performing evidence-based research
o Determining whether claims issues can be resolved internally or require client review
o Making recommendations to the client based on research and medical knowledge
o Presenting findings to the client on a weekly basis
o Reporting on claims metrics
- Reviews and responds to medical claims appeals.
- Coordinates with the Clinical Centers of Excellence (CCEs) to obtain medical claims records and other needed documentation to resolve claims’ issues.
- Researches medical code pricing using the FECA fee schedule and other pricing methodologies.
- Conducts medical claims audits to ensure quality control.
- Documents Medical Management processes, including medical claims review.
- Completes ad hoc research for the client.
- Registered nurse (RN)
- BSN or BA/BS required; Experience in lieu of degree will be considered
- 5 years of experience in acute care settings
- 2 years in Utilization Review (UR)/, Utilization Management (UM), and/or Case Management
- Experience with claims review in the acute care setting
- Certified Case Manager (CCM), Accredited Case Manager (ACM), or similar certification preferred
- Knowledge of Federal programs and payors, including CMS, OWCP, and Tricare preferred
- Must be familiar with coding, including ICD-10, CPT and HCPCS
- Experience with Quality Assurance review of medical claims preferred
- Experience with analyzing data and reporting on UR trends
- Experience with appeals and denials
- Knowledge of transitions of care
- Ability to identify areas to improve cost, quality, and utilization of care within a population
- Ability to maintain HIPAA compliance
- Well-versed in Microsoft Office products, including SharePoint
- Ability to obtain and maintain appropriate security clearance
- Knowledge of workers compensation claims is a plus
If you’re ready to take on a role that combines your clinical expertise with a passion for service, we’d love to hear from you. Apply now and become a vital part of the World Trade Center Health Program!
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