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Clinical Review Nurse I – Medicare Part A
Elevance Health. Review documentation and make clinical determinations for payment supporting claims submitted to Medicare .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in Medicare claims review, including clinical determinations and adherence to billing and coding practices. Strong communication skills are essential for effective collaboration with medical professionals and resolving appeals within regulatory timeframes.
Highest-signal resume keywords
RN LicenseMedicare Claims ReviewClinical ExperienceMedical Policy ComprehensionPart A Home Health and Hospice Experience
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
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Hard Skills
Clinical DeterminationsBilling and Coding PracticesMedical Review DecisionsGrievance InvestigationsClaims Assessment
Soft Skills
Clear CommunicationProblem Solving
Tools & Technologies
CMS Mainframe SystemMAS
Certifications & Qualifications
RN License
Industry Keywords
MedicarePart A AppealsSurgical ServicesICUMedical-Care Standards
About the role
Key responsibilities & impact- Review documentation and make clinical determinations for payment supporting claims submitted to Medicare
- Assess whether services and items billed are reasonable and necessary using national and local policies
- Ensure billed services and items follow accepted billing and coding practices and meet medical-care standards
- Adapt to a wide variety of medical review topics in Part A appeals
- Communicate clearly with medical doctors, nurses, and support personnel
- Make medical determinations about whether claims meet the member’s benefits
- Conduct investigations and reviews of member and provider grievances and appeals
- Generate written correspondence to providers, members, and regulatory entities
- Resolve appeals and grievances within regulatory timeframes
Requirements
What you’ll need- AS in nursing and minimum of 1 year of clinical experience; or any combination of education and experience providing an equivalent background
- Current unrestricted RN license required
- Foreign national applicants must have lived in the United States at least three of the past five years
- BS in nursing preferred
- Part A Home Health and Hospice claim review experience preferred
- Strong computer skills preferred
- Experience with MAS or other CMS mainframe system preferred
- Ability to comprehend medical policies and apply criteria effectively to make informed medical review decisions preferred
- Ability to communicate medical review decisions clearly and concisely preferred
- Part A Medicare experience strongly preferred
- Prior experience with Medicare claims review preferred
- Experience in surgical services and ICU strongly preferred
- Monday through Friday availability, 8 am–5 pm EST/CST
- Must reside within a reasonable commuting distance of a posting location unless an accommodation is granted
Benefits
Comp & perks- Comprehensive benefits package
- Incentive and recognition programs
- Equity stock purchase
- 401k contribution
- Merit increases
- Paid holidays
- Paid Time Off
- Incentive bonus programs
- Medical benefits
- Dental benefits
- Vision benefits
- Short-term disability benefits
- Long-term disability benefits
- 401(k) with company match
- Stock purchase plan
- Life insurance
- Wellness programs
- Financial education resources
- Virtual work flexibility
- Required in-person training sessions
- COVID-19 and Influenza vaccination coverage/requirement for certain roles