Medical/Clinical Review Nurse (Remote option available)

SELECT SOURCE INTERNATIONAL

Select Source International (SSI) has been serving major corporations for more than 15 years. At SSI, we believe in building a corporation with only the strongest and most capable individuals. Our world-class consultants have the expertise to meet our clients’ demands. Here at SSI, we pride ourselves on the fundamental belief that our team is essential to our company's growth. We assist our consultants every step of the way in order to match them to the best possible position for their skills.

Job Title: Medical/Clinical Review Nurse

Location: Durham, NC (Remote option available)

Duration: 3-6 Months

Job Description

Must have proficient written and oral communication skills.

Determines medical necessity, benefit eligibility and/or appropriate reimbursement allowances for complex claims and/or products by using clinical experience, medical literature, medical records, certificate guidelines, medical policy, and several complex and varied computer application software systems.

Identifies, documents, and escalates system and process problems. Through analysis, determines root cause and recommends possible solutions.

Defines, communicates, and follows up as appropriate on the root causes of errors to others.

Reviews physician-submitted and member-submitted claims for specified services, utilizing professional knowledge and developed criteria, to determine the medical necessity of the treatment.

Refers cases that do not meet criteria to the Medical Director with appropriate clinical analysis and summaries. Issues denials according to department protocols.

Documents outcome of reviews.

Identifies situations in which claims filing/coding guidelines are not being followed by providers; documents examples for referral to Network Management and/or Special Investigations for appropriate action.

Communicates with members and providers to obtain additional information.

Informs members, providers, and internal customers of claims status and determinations.

Reviews claims for Individual Business for possible misrepresentation as needed.

Gathers information and prepares documentation for internal review.

Best Regards,

Deepak Singh Tomar

Cell: 612-474-9508

Deepakt(at)selectsourceintl(dot)com

13911 Ridgedale Drive Suite 230 Minnetonka, Minnesota 55305

Disclaimer: Select Source International (SSI) does not tolerate discrimination against any applicant on the basis of gender, sexual orientation, race, religion, national origin, ethnicity, veteran status, disability, age, sexual preference or any other protected status designated by federal, state or local law. It is SSI’s policy to affirmatively recruit, hire, train, assign, transfer, evaluate, compensate, provide benefits, promote, demote, layoff, recall, and terminate employees on their own abilities, achievements and experiences. This policy applies to all SSI employee activities. SSI encourages diversity in hiring, recognizing that this enriches the work environment for all SSI associates and that a broad variety of perspectives enhances decision-making and creativity.

SSI is an Equal Opportunity Employer.

Job Type: Contract

Pay: $35.00 - $40.00 per hour

Education:

• Associate (Preferred)

Experience:

• Registered Nurse (RN): 5 years (Preferred)
• Medical/Clinical Review: 5 years (Preferred)
• Medical billing/coding/Claim: 3 years (Preferred)
• Medical records: 3 years (Preferred)

Work Location: In person