Medical Review Nurse

About SCAN

As one of the nation’s largest not-for-profit Medicare Advantage plans, serving more than 200,000 members in California, SCAN Health Plan has been a mission-driven organization dedicated to keeping seniors healthy and independent for over 40 years. SCAN employees are passionate about what they do, and understand that success is based on achieving the mission. Employees are afforded with the training and tools necessary to do their jobs and are rewarded for their efforts and recognized as experts in their fields. To learn more, visit scanhealthplan.com or follow us on social media: LinkedIn; Facebook; and Twitter.

The Job

Provide clinical review of medical claims and post service appeals. Facilitate appropriate investigation of issues and management of medical services, claims-billed charges, and benefit administration while maintaining SCAN timeframe standards.

You Will

Review and analyze pre and post payment of complex health care claims from a medical perspective.

Perform audits/reviews of medical claims per established criteria, identify need for medical record review, necessary documentation to support decision making process regarding appropriateness of claim, billed charges, benefit coverage.

Provide guidance to other staff members and accurately interpret and apply broad Centers for Medicare and Medicaid Services (CMS) guidelines to specific and highly variable situations.

Conduct review of claims data and medical records to make clinical decisions on the coverage, medical necessity, utilization and appropriateness of care per national and local policies as well as accepted medical standards of care.

Process workload and complete project work in the appropriate computer system(s).

Route identified clinical and /or risk issues to appropriate personnel e.g. Medical Director, Quality of Care (QOC) Nurse, Medical Management Specialist, Member Services, etc.

Review/prepare potential claims denials in conjunction with Medical Director.

Collaborate with Medical Director pursuant to adjudication of claims and post service appeals.

Participate in special projects/workgroups/committees (e.g., interdisciplinary workgroups, report analysis, Independent Review entity (IRE) etc.) as assigned and as necessary and appropriate.

Contribute to team effort by accomplishing related results as needed.

Actively supports the achievement of SCAN’s Vision and Goals

Your Qualifications

• Registered Nurse required. (Current and active California RN license in good standing.)
• May consider LVN/LPN with specific experience/work history.
• Certified Professional Coder/Certified Professional Utilization Reviewer preferred.
• 3-5 years of experience in clinical decision making, relative to Medicare patients.
• Experience using claims processing system.
• Knowledge of Medicare and Medi-Cal rules and regulations, including ability to research coverage guidelines/criteria.
• Background and/or training in use of nationally recognized, standardized clinical decision support criteria, as applicable to ensure consistency in clinical review. (e.g. InterQual, Milliman Care Guidelines).
• Experience/knowledge in the appeals/claims processing procedures in Managed Care or similar experience.
• Strong oral, written, and analytical skills.
• Working knowledge of the Managed Care regulatory agencies and the applicable laws and regulations.
• Ability to work independently and in a team environment.
• Proficient in MS Office.

Covid-19 Vaccination Policy

To ensure a healthy and safe work environment, if you are selected for this position, your job offer with SCAN Health will be contingent upon being fully vaccinated and providing proof of your COVID-19 vaccine within 3 days after your start date. Generally, you are considered fully vaccinated 14 days after receiving the last dose, as recommended by the manufacturer, of a vaccine that has been authorized by the FDA for use in the United States, including vaccinations that have been approved pursuant to an Emergency Use Authorization. If fully vaccinated outside of the United States, the vaccination must be listed for emergency use by the World Health Organization (WHO). If you cannot receive the vaccine because of a disability/medical reason or sincerely-held religious belief, you may request an accommodation to this requirement by contacting COVID-19 Vaccination Policy. Learn more about the COVID-19 vaccination here - https://www.cdc.gov/coronavirus/2019-ncov/vaccines/index.html

What's in it for you?

• A competitive compensation and benefits program
• An annual employee bonus program
• Robust Wellness Program
• Generous paid-time-off (PTO)
• Ten paid holidays per year, plus 1 additional floating holiday
• Excellent 403(b) Retirement Saving Plan with employer match
• Robust employee recognition program
• Tuition reimbursement
• An opportunity to become part of a team that makes a difference to our members and our community every day!

We're always looking for talented people to join our team! Qualified applicants are encouraged to apply now!

At SCAN we believe that it is our business to improve the state of our world. Each of us has a responsibility to drive Equality in our communities and workplaces. We are committed to creating a workforce that reflects our community through inclusive programs and initiatives such as equal pay, employee resource groups, inclusive benefits, and more.

SCAN is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c)