Appeals Review Nurse - RN

About SCAN

SCAN Group is a not-for-profit organization dedicated to tackling the most pressing issues facing older adults in the United States. SCAN Group is the sole corporate member of SCAN Health Plan, one of the nation’s leading not-for-profit Medicare Advantage plans, serving more than 270,000 members in California, Arizona, and Nevada. SCAN has been a mission-driven organization dedicated to keeping seniors healthy and independent for more than 40 years and is known throughout the healthcare industry and nationally as a leading expert in senior healthcare. SCAN employees are a group of talented, passionate professionals who are committed to supporting older adults on their aging journey, while also innovating healthcare for seniors everywhere. Employees are provided in-depth training and access to state-of-the-art tools necessary to do their jobs, as well as development and growth opportunities. SCAN takes great pride in recognizing our team members as experts in their fields and rewarding them for their efforts. If you are interested in becoming part of an organization that is innovating senior healthcare visit www.thescangroup.org, www.scanhealthplan.com, or follow us on LinkedIn, Facebook, and Twitter.

The Job

Provide clinical review of medical claims, Pre-service and post service appeals. Facilitate appropriate investigation of issues and management of medical services, claims-billed charges, and benefits administration while maintaining SCAN timeframe standards.

You Will

Review and analyze pre and post payment and denials of complex health care claims or services from a medical perspective.

Perform audits/reviews of medical claims and service denials per established criteria, identify need for medical record review, necessary documentation to support decision making process regarding appropriateness of claim, billed charges, benefit coverage for denied services.

Provide guidance to other staff members and accurately interpret and apply broad Centers for Medicare and Medicaid Services (CMS) guidelines to specific and highly variable situations.

Conduct review of claims data and medical records to make clinical decisions on the coverage medical necessity, utilization, and appropriateness of care per national and local policies as well as accepted medical standards of care.

Process workload and complete project work in the appropriate computer system(s).

Route identified clinical and/or risk issues to appropriate personnel e.g., Medical Director, Quality of Care (QOC) Nurse, Medical Management Specialist, Member Services, etc.

Review/prepare potential claims denials/service denials in conjunction with Medical Director.

Collaborate with Medical Director pursuant to adjudication of claims and pre/post service appeals.

Participate in special projects/workgroups/committees (e.g., interdisciplinary workgroups, report analysis, Independent Review entity (IRE) etc.) as assigned and as necessary and appropriate.

Contribute to team effort by accomplishing related results as needed.

Actively supports the achievement of SCAN’s Vision and Goals.

Other duties as assigned.

Your Qualifications

Completed Nursing Degree or Diploma required.

Current and active RN License in good standing required.

Certified Professional Coder preferred.

Certified Professional Utilization Reviewer preferred.

3-5 years of experience in clinical decision making, relative to Medicare patients.

Experience using claims processing system preferred.

Knowledge of Medicare and Medi-Cal rules and regulations, including ability to research coverage guidelines/criteria.

Background and/or training in use of nationally recognized, standardized clinical decision support criteria, as applicable to ensure consistency in clinical review. (e.g. InterQual, Milliman Care Guidelines).

Experience/knowledge in the appeals/claims processing procedures in Managed Care or similar experience.

Working knowledge of the Managed Care regulatory agencies and the applicable laws and regulations.

What's in it for you?

• Base salary range: $38.60 to $61.78 per hour
• An annual employee bonus program
• Robust Wellness Program
• Generous paid-time-off (PTO)
• Ten paid holidays per year, plus 1 additional floating holiday
• Excellent 401(k) Retirement Saving Plan with employer match and contribution
• Robust employee recognition program
• Tuition reimbursement
• An opportunity to become part of a team that makes a difference to our members and our community every day!

We're always looking for talented people to join our team! Qualified applicants are encouraged to apply now!

At SCAN we believe that it is our business to improve the state of our world. Each of us has a responsibility to drive Equality in our communities and workplaces. We are committed to creating a workforce that reflects our community through inclusive programs and initiatives such as equal pay, employee resource groups, inclusive benefits, and more.

SCAN is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.

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Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c)