Description:
Job Title:
Medical Review Nurse
Market Title:
Medical Review Nurse
Coventry Health Care is seeking a Review Nurse in a number of our Service Centers. As a strategic member of the Customer Service Operations (CSO) team, the successful candidate will be responsible for reviewing claims and medical history for possible pre-existing conditions. Additionally, coordinate with claims operations, Health Plan medical management and Medical Underwriting to conduct investigations.
ESSENTIAL RESPONSIBILITIES:
Coordinate, directs and performs retrospective reviews of individual medical history to identify possible pre-existing conditions.Conducts analysis and research of medical and claims history to make payment determination. Identifies and recommends opportunities for cost savings and improving outcomes. Actively identifies possible fraud/misrepresentation cases. Prepares cases for referral to medical underwriting and Health Plan medical management Participates/facilitates fraud review hearings. Performs other duties as required.
Qualifications:
Basic Qualifications:
Nurse with a current state RN license required. Previous (3-5 years) clinical experience.Knowledge of medical terminology and ICD-9,CPT-4 and HCPCS coding experience.
Preferred Qualifications:.
Bachelor’s degree and/or Certified Professional Code–CPC-H preferred.Working knowledge of coordination of benefits and health care products under both fully insured and self-funded arrangements.
Other:
Highly self-motivated and able to work well under stress in a fast-paced environment.Excellent organizational aptitude and high attention to details.Strong listending and interpersonal skills; skilled at developing and maintaining effective working relationshipsDemonstrates responsiveness and a sense of urgency when dealing with custoemrs.Effective verbal and written communication skills.Strong analytical and problem-solving skills.Strong organizational skills with ability to multi-task well.Must be able to absorb and apply new and changing information.Possess ability to maintain production levels and quality goals.Able to maintain regular and consistent attendance in accordance with company and departmental policies and procedures.Coventry Health Care, a $12.2 billion Fortune 500 organization, is a national managed health care company with nearly 5.1 million members in all 50 states. At Coventry Health Care, we are driven to ensure that every person and organization we serve receives the greatest possible value for their health care investment. We do this by providing a full range of competitive products through our seven core businesses – Commercial Risk, Medicare Advantage, Medicare Part D, Medicaid, Workers' Comp Services, Federal Employees Health Benefits Plan and Network Rental.
We are committed to constantly improving our low-cost platform so that we can deliver the products and services that our customers want at a price they can afford. Coventry has the expertise, the experience, and the agility to craft the new products, the new processes, and the new service needed to make healthcare more accessible to all Americans.
We offer a competitive salary, excellent benefits (401K with company matching, comprehensive benefits including medical, dental, and tuition reimbursement), vacation and sick time. This is a highly visible role dealing with business partners across the division and corporation, and being a part of motivating a dynamic team!
Please apply directly to http://jobs.coventryhealthcare.com/ and refer to Req# 1311054, Medical Review Nurse.
Coventry Health Care is an Affirmative Action/Equal Opportunity Employer, and we are committed to building a talented and diverse team.
Job: Professionals
Primary Location: Moon Township, PA, US
Other Locations: Cranberry Township-Pennsylvania-United States,Erie-Pennsylvania-United States,Harrisburg-Pennsylvania-United States,State College-Pennsylvania-United States,Bismarck-North Dakota-United States,Scottsdale-Arizona-United States
Organization: 10750 - Service Center - Central Admin
Schedule: Full-time
Job Posting: 2013-03-25 00:00:00.0
Job ID: 1311054
Job Title:
Medical Review Nurse
Market Title:
Medical Review Nurse
Coventry Health Care is seeking a Review Nurse in a number of our Service Centers. As a strategic member of the Customer Service Operations (CSO) team, the successful candidate will be responsible for reviewing claims and medical history for possible pre-existing conditions. Additionally, coordinate with claims operations, Health Plan medical management and Medical Underwriting to conduct investigations.
ESSENTIAL RESPONSIBILITIES:
Coordinate, directs and performs retrospective reviews of individual medical history to identify possible pre-existing conditions.Conducts analysis and research of medical and claims history to make payment determination. Identifies and recommends opportunities for cost savings and improving outcomes. Actively identifies possible fraud/misrepresentation cases. Prepares cases for referral to medical underwriting and Health Plan medical management Participates/facilitates fraud review hearings. Performs other duties as required.
Qualifications:
Basic Qualifications:
Nurse with a current state RN license required. Previous (3-5 years) clinical experience.Knowledge of medical terminology and ICD-9,CPT-4 and HCPCS coding experience.
Preferred Qualifications:.
Bachelor’s degree and/or Certified Professional Code–CPC-H preferred.Working knowledge of coordination of benefits and health care products under both fully insured and self-funded arrangements.
Other:
Highly self-motivated and able to work well under stress in a fast-paced environment.Excellent organizational aptitude and high attention to details.Strong listending and interpersonal skills; skilled at developing and maintaining effective working relationshipsDemonstrates responsiveness and a sense of urgency when dealing with custoemrs.Effective verbal and written communication skills.Strong analytical and problem-solving skills.Strong organizational skills with ability to multi-task well.Must be able to absorb and apply new and changing information.Possess ability to maintain production levels and quality goals.Able to maintain regular and consistent attendance in accordance with company and departmental policies and procedures.Coventry Health Care, a $12.2 billion Fortune 500 organization, is a national managed health care company with nearly 5.1 million members in all 50 states. At Coventry Health Care, we are driven to ensure that every person and organization we serve receives the greatest possible value for their health care investment. We do this by providing a full range of competitive products through our seven core businesses – Commercial Risk, Medicare Advantage, Medicare Part D, Medicaid, Workers' Comp Services, Federal Employees Health Benefits Plan and Network Rental.
We are committed to constantly improving our low-cost platform so that we can deliver the products and services that our customers want at a price they can afford. Coventry has the expertise, the experience, and the agility to craft the new products, the new processes, and the new service needed to make healthcare more accessible to all Americans.
We offer a competitive salary, excellent benefits (401K with company matching, comprehensive benefits including medical, dental, and tuition reimbursement), vacation and sick time. This is a highly visible role dealing with business partners across the division and corporation, and being a part of motivating a dynamic team!
Please apply directly to http://jobs.coventryhealthcare.com/ and refer to Req# 1311054, Medical Review Nurse.
Coventry Health Care is an Affirmative Action/Equal Opportunity Employer, and we are committed to building a talented and diverse team.
Job: Professionals
Primary Location: Moon Township, PA, US
Other Locations: Cranberry Township-Pennsylvania-United States,Erie-Pennsylvania-United States,Harrisburg-Pennsylvania-United States,State College-Pennsylvania-United States,Bismarck-North Dakota-United States,Scottsdale-Arizona-United States
Organization: 10750 - Service Center - Central Admin
Schedule: Full-time
Job Posting: 2013-03-25 00:00:00.0
Job ID: 1311054