Top 62 Claim review nurse Jobs in Pennsylvania

Clinical Appeals Nurse - Full Time Remote - Jefferson Health
Thomas Jefferson University and Hospitals —Philadelphia, PA
- Full-time
- Remote
- Microsoft Word
- Nursing
- RN License
- AD&D insurance
- Disability insurance
Medical Records Examiner
Commonwealth of PA —Harrisburg, PA
- $69,086 - $104,959 a year
- Full-time
- RN License
- Mid-level
- Office
- Paid parental leave
- Health insurance
3d
RN Readmission Manager, Payment Integrity
Centene Corporation —Pennsylvania
- $87,700 - $157,800 a year
- Full-time
- Remote
- Nursing
- RN License
- 3 years
- Paid holidays
- Health insurance
12d
Contract Clinical Auditor
Marsh McLennan Agency —Conshohocken, PA
- $175 a day
- Part-time
- Remote
- RN License
- HIPAA
- Mid-level
Nurse Reviewer RN
Federal Hearings And Appeals —Wilkes-Barre, PA
- $67,500 - $75,000 a year
- Full-time
- RN License
- Mid-level
- Analysis skills
Quick Apply
Nursing Services Consultant
Commonwealth of PA —Scranton, PA
- $69,086 - $104,959 a year
- Full-time
- Nursing
- RN License
- Mid-level
- Paid parental leave
- Health insurance
4d
Case Manager RN
CVS Health —Pennsylvania
- $60,522 - $129,615 a year
- Full-time
- Remote
- Google Workspace
- Nursing
- Microsoft Excel
- Health insurance
- Dental insurance
5d
RN REGISTERED NURSE ASSESSMENT COORDINATOR
Elan Skilled Nursing —Scranton, PA
- From $42 an hour
- Nursing
- Skilled nursing facility
- RN License
- Health insurance
- Dental insurance
Quick Apply
Licensed Practical Nurse Southeastern Veterans' Center (2nd and 3rd Shift)
Commonwealth of PA —Spring City, PA
- $68,914 - $86,022 a year
- Full-time
- Nursing
- Nursing home
- Pass drug screening
- Paid parental leave
- Health insurance
Registered Nurse - Assessment Coordinator
US Veterans Health Administration —Erie, PA
- $67,742 - $132,027 a year
- Online Application
- Background check
- Nursing
- Doctoral degree
- Paid holidays
- Dental insurance
11d
Registered Nurse Instructor
Commonwealth of PA —Erie, PA
- $89,882 - $111,956 a year
- Full-time
- Nursing
- RN License
- Mid-level
- Paid parental leave
- Health insurance
5d
Clinical Appeals Analyst | PAM Health Corporate
PAM Health, LLC —Enola, PA
- Full-time
- RN License
- Writing skills
- Licensed Clinical Social Worker
Quick Apply
Nurse Manager 1
Commonwealth of PA —Erie, PA
- $95,995 - $145,965 a year
- Weekends as needed
- Nursing
- RN License
- Mid-level
- Paid parental leave
- Health insurance
5d
Registered Nurse - Chief Quality and Patient Safety
US Veterans Health Administration —Altoona, PA
- $129,623 - $172,391 a year
- Online Application
- Background check
- Nursing
- Doctoral degree
- Paid holidays
- Dental insurance
3d
Registered Nurse - Chief, Office of Performance & Quality (OPQ)
US Veterans Health Administration —Erie, PA
- $130,800 - $173,964 a year
- Online Application
- Background check
- Nursing
- Doctoral degree
- Paid holidays
- Dental insurance
12d
Registered Nurse - Short Stay Unit
US Veterans Health Administration —Lebanon, PA
- $80,654 - $138,421 a year
- Online Application
- Background check
- Nursing
- Doctoral degree
- Paid holidays
- Loan repayment program
4d
Nurse (Intermittent Resource Pool Nurse)
US Veterans Health Administration —Coatesville, PA
- $81,491 - $143,608 a year
- Online Application
- Background check
- Nursing
- Doctoral degree
- Health insurance
- Flexible spending account
Registered Nurse SCI Phoenix
Commonwealth of PA —Collegeville, PA
- $93,888 - $111,956 a year
- Full-time
- Nursing
- RN License
- Teaching
- Paid parental leave
- Health insurance
14d
R&E Nurse- Med Care Services (675886)
TulaRay —Harrisburg, PA
- Contract
- Nursing
- Microsoft Excel
- RN License
Quick Apply
Registered Nurse Torrance State Hospital
Commonwealth of PA —Torrance, PA
- $93,888 - $111,956 a year
- Overtime
- Nursing
- Patient monitoring
- RN License
- Free parking
- Paid parental leave
11d

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claim review nurse jobs near pennsylvania

Clinical Appeals Nurse - Full Time Remote - Jefferson Health

Thomas Jefferson University and Hospitals -
Philadelphia, PA

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Job Details

Full-time

Benefits

AD&D insurance
Disability insurance
Health insurance
Dental insurance
Flexible spending account
Tuition reimbursement
Vision insurance
Life insurance
Retirement plan
Prescription drug insurance

Qualifications

Microsoft Word
Nursing
RN License
Health insurance policy knowledge
Word embeddings
Medical coding guidelines
InterQual
Utilization management
Resource utilization in healthcare
Clinical documentation improvement
Epic
Clinical documentation standards
Documentation review
Medical record review for billing accuracy
Documentation reviews
Nursing

Full Job Description

Job Details

Reviews payor denials and audits for potential lost revenue. Writes comprehensive, factual arguments to present to third-party payers, medical review boards, or other responsible parties applying clinical criteria to establish medical necessity. Functions as a hospital liaison with external third-party payors to appeal denied claims. Works closely with Physician advisor team to facilitate appeals to payors. Monitors and reports payor trends to management team.

Job Description

Clinical Appeals Nurse - Full Time Remote - Jefferson Health

Articulates the job's main responsibilities. This is not intended to be an exhaustive list of all essential functions or all duties performed. The essential functions listed below and percentage of time may vary between departments and locations, and are subject to change based on management discretion and organizational needs. Other responsibilities may be assigned at the discretion of management to meet organizational needs.

Creates an appeal letter to uphold the procedure based on medical policy guidelines of the payor and the documentation found in the hospital/physician information system.
Facilitates write off accounts that cannot provide adequate medical necessity or documentation for the payor to meet their guidelines.
Investigates and coordinates completion of patient records required to retrospectively precertify accounts and appeal insurance denials.
Contacts insurance companies and conducts appeals via telephone or email.
Coordinates appeals that need a physician's input for the payor and writes off claims that have no further appeal rights.
Identifies areas for revenue loss due to documentation or processes not being reimbursable thru payors.
Ensures that all appeals are sent to the correct payor within the appeal guidelines.
Ensures compliance with regulatory and accrediting requirements.
Reviews claim documentation and pulls supporting medical documentation from the system to support the medical policy guidelines of the payor.
Searches for supporting clinical evidence to support appeal arguments when existing resources are unavailable.

Qualifications:

The requirements listed below are representative of the knowledge, skill, and/or ability required or preferred.

Education - Required

Bachelor’s Degree Nursing or
Specialized Diploma

Experience - Required

10 years of clinical or case management/utilization review experience

Knowledge, Skills and Abilities - Required

Ability to read medical charts and identify deficiencies in documentation content.
Ability to adapt to ongoing changes within the health insurance industry in order to effectively implement positive changes.
Knowledge of Interqual/medical policy criteria, case management principles, utilization review, and hospital departmental procedures.
Knowledge of coding for payment of claims.
Insurance knowledge of payors and their unique rules.
Epic workflow experience with notes in account history and WQ workflows.
Intermediate Excel and MS Word experience.
Must complete RCE Training and pass test with 80% or better.

Licenses and Certifications - Required

RN - Licensed Registered Nurse_PA - State of Pennsylvania

Work Shift

Workday Day (United States of America)

Worker Sub Type

Regular

Employee Entity

Thomas Jefferson University

Primary Location Address

1101 Market, Philadelphia, Pennsylvania, United States of America

Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University , home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200+ undergraduate and graduate programs to more than 8,300 students. Jefferson Health , nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years.

Jefferson is committed to providing equal educational and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status.

Benefits

Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts. Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service. All colleagues, including those who work less than part-time (including per diem colleagues, adjunct faculty, and Jeff Temps ), have access to medical (including prescription) insurance.

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Refine Your Search

claim review nurse jobs in pennsylvania

Clinical Appeals Nurse - Full Time Remote - Jefferson Health

Medical Records Examiner

RN Readmission Manager, Payment Integrity

Contract Clinical Auditor

Nurse Reviewer RN

Nursing Services Consultant

Case Manager RN

RN REGISTERED NURSE ASSESSMENT COORDINATOR

Licensed Practical Nurse Southeastern Veterans' Center (2nd and 3rd Shift)

Registered Nurse - Assessment Coordinator

Registered Nurse Instructor

Clinical Appeals Analyst | PAM Health Corporate

Nurse Manager 1

Registered Nurse - Chief Quality and Patient Safety

Registered Nurse - Chief, Office of Performance & Quality (OPQ)

Registered Nurse - Short Stay Unit

Nurse (Intermittent Resource Pool Nurse)

Registered Nurse SCI Phoenix

R&E Nurse- Med Care Services (675886)

Registered Nurse Torrance State Hospital

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