Nurse Reviewer

The Nurse Reviewer position is responsible for supporting and conducting reviews and determinations for independent dispute resolutions at both the Federal and State levels. This role involves analyzing medical records, ensuring proper documentation, and providing quality assurance checks to support the final determination. IDRE Nurse Reviewers must ensure that their decisions are well-supported with robust rationale and comply with Federal or State guidelines. This position will be responsible for resolving claim disputes submitted by various parties, such as physicians, hospitals, institutions, pharmacies, and other licensed healthcare providers. Additionally, responsibilities will include resolving disputes submitted to the Federal Independent Review (IDR) process. IDRs conduct impartial reviews of healthcare services to resolve disputes between healthcare providers. facilities and payers. IDRs provide objective assessments of billing, coding, and other issues related to disputed claims. The role requires conducting all job duties efficiently, promptly, productively, consistently, and courteously while maintaining a high level of professionalism.

The Nurse Reviewer position is responsible for supporting and conducting reviews and determinations for independent dispute resolutions at both the Federal and State levels. This role involves analyzing medical records, ensuring proper documentation, and providing quality assurance checks to support the final determination. IDRE Nurse Reviewers must ensure that their decisions are well-supported with robust rationale and comply with Federal or State guidelines. This position will be responsible for resolving claim disputes submitted by various parties, such as physicians, hospitals, institutions, pharmacies, and other licensed healthcare providers. Additionally, responsibilities will include resolving disputes submitted to the Federal Independent Review (IDR) process. IDRs conduct impartial reviews of healthcare services to resolve disputes between healthcare providers. facilities and payers. IDRs provide objective assessments of billing, coding, and other issues related to disputed claims. The role requires conducting all job duties efficiently, promptly, productively, consistently, and courteously while maintaining a high level of professionalism. 

• Conduct an initial assessment of documentation from both the initiating and responding parties.
• Review submitted documentation to identify missing documents and determine what is required to resolve the dispute. Follow procedures to obtain the appropriate documentation.
• Determine the appropriate type of clinical reviewer necessary to complete the case, such as a medical coder or a physician.
• Prepare documents for the arbitrator reviewer assigned and provide instructions as needed.
• Collaborate with the legal team to facilitate resolution of disputes.
• Draft professional determination correspondence.
• Perform quality assurance checks on determinations according to Federal or State guidance.
• Audit and analyze patient records to ensure appropriate determination.
• Stay current with regulation changes and perform research on a case-by-case basis.
• Deliver high-quality, professional determinations free of grammar and spelling errors.
• Amend reports with additional clinical information when necessary.
• Participate in an interdisciplinary health care team to achieve positive outcomes.

Required Qualification:

• Maintain an active license in nursing ( at a minimum, RN required)
• Five years of full-time equivalent experience providing direct care to patients
• Hold a non-restricted nursing license in any state in the US.
• Ability to analyze clinical documentation and apply appropriate guidelines.
• Strong oral and written communication skills with excellent customer service.
• Ability to multitask and adapt to a fast-paced environment.
• Strong organizational skills and attention to detail
• Knowledge of claim review processes includes billing, Current Procedural Terminology (CPT) coding, and Explanation of Benefits.
• Familiarization with navigating electronic documents like PDFs, Microsoft Excel, Microsoft Word, and experience using Microsoft Outlook.
• Familiarization with electronic data repositories such as SharePoint and/or ShareFile.
• Exceptional skills in managing sensitive and confidential information.
• Strong organizational abilities, written, and verbal communication skills in English.
• Ability to work both independently and collaboratively with other team members to include clinical reviewers, physicians, and attorneys.
• Skilled in prioritizing tasks to align with business needs and assignments.
• Appeal and/or claim dispute-related experience.
• Medical Coding Certification preferred
• Experience with Utilization Review preferred

Commence.AI is committed to providing equal employment opportunities to all applicants, including individuals with disabilities. If you require a reasonable accommodation to participate in the application process due to a disability, please contact Human Resources at (757) 306-4920 or hr@commence.ai. Please note that unless you are requesting accommodation, all applications must be submitted through our online application system.