- Specialty: Utilization Review
- Job type: Full-time
- Salary: $77,905 – $116,858 / yr
- License states: California
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At a glance
Remote RN clinical review of medical claims and post-service appeals for a Medicare Advantage plan. Applies CMS guidelines and medical necessity criteria to complex claims and prepares potential denials with the Medical Director. Requires an active California RN license and 3-5 years of Medicare clinical decision-makin
Today, SCAN is a nonprofit health organization serving more than 500,000 people across Arizona, California, Nevada, New Mexico, Texas, and Washington, with over $8 billion in annual revenue. With nearly five decades of experience, we have built a distinctive, values-driven platform dedicated to improving care for older adults.
Our work spans Medicare Advantage, fully integrated care models, primary care, care for the most medically and socially complex populations, and next-generation care delivery models. Across all of this, we are united by a shared commitment: combining compassion with discipline, innovation with stewardship, and growth with integrity.
SCAN Group is a not-for-profit organization dedicated to tackling the most pressing issues facing older adults in the United States. SCAN Group is the sole corporate member of SCAN Health Plan, one of the nation’s leading not-for-profit Medicare Advantage plans, serving more than 300,000 members in California, Arizona, Nevada, Texas, New Mexico & Washington. SCAN has been a mission-driven organization dedicated to keeping seniors healthy and independent for more than 45 years and is known throughout the healthcare industry and nationally as a leading expert in senior healthcare. SCAN employees are a group of talented, passionate professionals who are committed to supporting older adults on their aging journey, while also innovating healthcare for seniors everywhere. Employees are provided in-depth training and access to state-of-the-art tools necessary to do their jobs, as well as development and growth opportunities. SCAN takes great pride in recognizing our team members as experts in their fields and rewarding them for their efforts. If you are interested in becoming part of an organization that is innovating senior healthcare visit www.thescangroup.org, www.scanhealthplan.com, or follow us on LinkedIn, Facebook, and Twitter.
Provide clinical review of medical claims and post service appeals. Facilitate appropriate investigation of issues and management of medical services and benefits administration while maintaining SCAN timeframe standards.
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 coverages
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) as assigned and as necessary and appropriate
Process workload and complete project work in the appropriate computer system(s). Contribute to team effort by accomplishing related results as needed.
Route identified clinical and/or risk issues to appropriate personnel eg, 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 (eg, interdisciplinary workgroups, report analysis, independent review entity (IRE) etc. as assigned and as necessary and appropriate.
We seek Rebels who are curious about AI and its power to transform how we operate and serve our members.
Actively support the achievement of SCAN’s Vision and Goals.
Other duties as assigned.
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.
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)
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