Nurse Reviewer

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🔥 16 minutes ago

⚔️ Virginia – Remote

⚔️ Virginia – Remote

💵 $45 - $55 / hour

⏱ Part Time

🟡 Mid-level

🟠 Senior

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LivantaLLC

WebsiteLinkedInAll Job Openings

201 - 500 employees

Founded 2004

⚕️ Healthcare Insurance

📚 Education

Healthcare Insurance • Education • Data Management

Livanta LLC is a technology-enabled organization dedicated to advancing healthcare quality through innovation. It specializes in providing services to patients, caregivers, healthcare providers, and payers, focusing on improving health outcomes, navigating healthcare systems, and ensuring payment accuracy. Livanta is recognized as the largest Medicare Quality Improvement Organization and offers a range of services including quality oversight, auditing, advocacy, and data analytics to enhance patient care and safety while managing healthcare costs effectively.

📋 Description

• Conduct an initial assessment of documentation from both the initiating and responding parties. • Review submitted documentation to identify missing documents and determine what is required to resolve the dispute. • Follow procedures to obtain the appropriate documentation. • Determine the appropriate type of clinical reviewer necessary to complete the case, such as a medical coder or a physician. • Prepare documents for the arbitrator reviewer assigned and provide instructions as needed. • Collaborate with the legal team to facilitate resolution of disputes. • Draft professional determination correspondence. • Perform quality assurance checks on determinations according to Federal or State guidance. • Audit and analyze patient records to ensure appropriate determination. • Stay current with regulation changes and perform research on a case-by-case basis. • Deliver high-quality, professional determinations free of grammar and spelling errors. • Amend reports with additional clinical information when necessary. • Participate in an interdisciplinary health care team to achieve positive outcomes.

🎯 Requirements

• Maintain an active license in nursing ( at a minimum, RN required) • Five years of full-time equivalent experience providing direct care to patients • Hold a non-restricted nursing license in any state in the US. • Ability to analyze clinical documentation and apply appropriate guidelines. • Strong oral and written communication skills with excellent customer service. • Ability to multitask and adapt to a fast-paced environment. • Strong organizational skills and attention to detail • Knowledge of claim review processes includes billing, Current Procedural Terminology (CPT) coding, and Explanation of Benefits. • Familiarization with navigating electronic documents like PDFs, Microsoft Excel, Microsoft Word, and experience using Microsoft Outlook. • Familiarization with electronic data repositories such as SharePoint and/or ShareFile. • Exceptional skills in managing sensitive and confidential information. • Strong organizational abilities, written, and verbal communication skills in English. • Ability to work both independently and collaboratively with other team members to include clinical reviewers, physicians, and attorneys. • Skilled in prioritizing tasks to align with business needs and assignments. • Appeal and/or claim dispute-related experience. • Medical Coding Certification preferred • Experience with Utilization Review preferred