Nurse Reviewer, RN

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🔔 Pennsylvania – Remote

🔔 Pennsylvania – Remote

💵 $67.5k - $95k / year

⏰ Full Time

🟢 Junior

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FHAS, LLC

WebsiteLinkedInAll Job Openings

51 - 200 employees

Founded 1996

⚕️ Healthcare Insurance

🏛️ Government

🤝 B2B

Healthcare Insurance • Government • B2B

FHAS, LLC is a provider of data-driven medical review, appeals management, independent dispute resolution (IDR), and hearings/adjudication services for health plans, federal and state agencies, and government contractors. The company combines accredited clinical and legal expertise with AI-augmented, cloud-based platforms to deliver scalable, compliant reviews, claims adjudication, provider education, and dispute resolution that reduce improper payments, improve regulatory compliance, and accelerate case outcomes.

📋 Description

• Provide timely review and determination of medical claims, including prior authorization, appeals, and/or any other type of medical claims; • Analyze medical records related to the case file; • Review and interpret Local Coverage Determination (LCD), National Coverage Determination (NCD) policies, and other federal regulations; • Apply appropriate regulatory citations, including health plan policies, NCD/LCDs, and/or other regulations to each claim as it relates to the item or issue; • Formulate a narrative decision citing relevant regulatory back-up documentation contained within the medical record; • Adjudicate claim based on the regulations and documentation contained within the medical record; • Attend FHAS and/or client Lunch & Learn sessions and/or general training sessions on site as needed. • Complete IRR surveys in a timely fashion as required by the prime contractor Maintain a 97% or higher quality score work experience requirements

🎯 Requirements

• 1+ years clinical experience required; coding, utilization, and/or medical chart review preferred. • Professional Coding Certification preferred. • Detailed knowledge of Medicare regulations and guidelines, polices, and payor reimbursements preferred. • Knowledge of CPT, HCPCS, ICD-10 codes and coding guidelines. • Ability to identify Medicare billing and payment irregularities. • Must be able to support review findings by utilizing exceptional analytical, written and oral communication skills. • Ethical, self-motivated and results oriented team player. • Strong analytical, verbal and written communication skills. • Outstanding people skills and ability to effectively review findings /results with management. • Must be proficient with PC and related software programs. • Excellent organizational skills. • Must be a team player. • Must possess a current, unrestricted State license as a Registered Nurse (RN),as required by contract(s).