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Saint-Bruno-de-Montarville

    Utilization Management Nurse - Saint-Bruno-de-Montarville, Canada - TALENT Software Services

    TALENT Software Services
    TALENT Software Services Saint-Bruno-de-Montarville, Canada

    1 week ago

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    Contract
    Description

    The Medicare Member Appeals and Grievances team is responsible for clinically reviewing member appeals and grievances that are the result of either a preservice, post-service or claim denial.

    The Medicare Appeals and Grievances RN Senior will report to the Appeals and Grievances Manager. In this role you will perform accurate and timely clinical review of Member-initiated appeals.

    The RNs perform first level appeal reviews for members utilizing the National Coverage Determination (NCD) guidelines, Local Coverage Determination (LCD) Guidelines, Milliman Care Guidelines, and nationally recognized sources such as NCCN and ACOG.

    The successful RN candidate will review both inpatient and outpatient Medicare member appeals for benefits, medical necessity, coding accuracy and medical policy compliance.


    Required Skills (top non-negotiables):
    Knowledge of Medicare and benefit reviews
    Requires years of health insurance or related experience
    Demonstrate the ability to act independently using sound clinical judgement

    Preferred Skills (nice to have)
    .Knowledge of CPT, ICD-, HCPCS and billing practices
    .Excellent communication skills
    well in a fast paced team environment
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