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Medical Nurse Reviewer

Company: Highmark Medicare Services, Inc.,

Location

Job Description:

Highmark Medicare Services, Inc., a Camp Hill, PA based company, is responsible for the combined administration of Medicare Part A and Part B fee-for-service claims for the states of Pennsylvania, Delaware, Maryland, New Jersey and the District of Columbia. Like its parent company, Highmark Inc., Highmark Medicare Services, Inc. embraces workforce diversity as a means to best serve its increasingly diverse customer base. By tapping into the different skills, abilities, and perspectives of a diverse workforce, Highmark Medicare Services, Inc. is able to serve and anticipate the needs of a changing and expanding marketplace. We are currently seeking candidates for the following position in Camp Hill, PA:

Medical Nurse Reviewer
This position is responsible for the following: Review and analyze pre and post pay complex health care claims from a medical perspective. Make decisions concerning the validity of health care claims and levels of payment by applying standard concepts as outlined in policies, procedures, and The Centers for Medicare and Medicaid Services (CMS) and within Highmark Medicare Services. Perform some level of educational activities in the provider community. Lead specialty committees and contribute to the establishment and revision of policy and procedure guidelines for the department. Identify quality-related problems and notify management appropriately. Recommend process improvements designed to improve accuracy, timeliness of processing, and/or eliminate manual effort. Overnight travel on occasion to participate in special projects that include interdisciplinary workgroups.

REQUIRED QUALIFICATIONS:
High School Diploma or GED.1-3 years experience in clinical decision making. Current Clinical RN Licensure.

PREFERRED QUALIFICATIONS:
Bachelor’s degree in Nursing, MSN. Certified Professional Coder/Certified Professional Utilization Review Certification in or equivalent training in a medical specialty. 3-5 years experience in clinical decision making, relative to Medicare patients. 3-5 years of experience working on a personal computer in Microsoft Windows or similar environment as well as experience with Excel, PowerPoint, Lotus Notes, a claims processing system (e.g., MCS/FISS), etc.

To submit your resume for consideration, go to the following website: www.highmark.com and click on the Careers link under the About Highmark section of the site. Follow the instructions there to view our current open positions. To apply for this position, use reference #58473. Highmark Medicare Services, Inc., an equal opportunity employer, strives to capitalize on the strengths of individual differences and the advantages of an inclusive workplace. Qualified applicants will receive consideration for employment without regard to race, color, ethnicity, sex, marital status, religion, creed, national origin, disability, veteran’s status, sexual orientation or any other category protected by applicable federal, state or local laws.
 

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