Medical Review Nurse - Behavioral Health


Centene Coproration


Posted Under: Baton Rouge, Louisiana jobs in Healthcare; Healthcare jobs in zipcode 70801
Posted On: 2019-07-13 00:00:00

Description: Position Purpose: Perform medical review provider claims, authorizations, and medical records to achieve resolution of authorization issues that result in claims denials or pended claims. Perform retrospective review for medical necessity appeals against medical review criteria to make benefit of determinations. Utilize standard methodology and medical criteria sets to analyze and interpret member and/or provider claims, eligibility and quality data. Perform retrospective readmission review of hospital and physician claims for admission appropriateness, coding, length of stay, and pricing Identify potential process modification, changes, or automation to improve performance, quality, and efficiency Manage the review of medical claims, records, and authorizations for billing, coding and other compliance or reimbursement related issues Implement and maintain production and quality standards for he medical review process Receive and respond to inquiries from Claims, Prior Authorization, and Concurrent Review staff. Perform retrospective review of high dollar claims for benefit and pricing-determination Maintain departmental records, correspondence and files Work collaboratively with Finance to determine appropriateness of pricing Assist wit other clinical function of medical review