-
Medical Claims Review Nurse
New York, NY
Essential Duties: The nurse reviewer's primary duty will be to provide a professional opinion to the claims department regarding authorization. The employee will provide an analytical decision about services rendered according to the department guidelines and members' benefits. The nurse reviewer will support the unit goals and objectives. * Review and analyze facility and professional claims against members' policies [benefits] and CMS guidelines utilizing the care system. * Review members' medical records as necessary according to departmental policies and procedures. * Investigate and formulate responses to member grievances and appeals regarding quality of medical care delivered by or under the auspices of EmblemHealth providers. * Triage cases to determine level of appeal and...
See job listing >
Send this job to a friend
