Clinical Review Nurse I- Medicare Part A
Core
Review Medicare Part A claims documentation to determine payment eligibility and reasonableness of services.
Role type
Clinical Review Nurse I (Medicare)
Builds
Claims adjudication decisions for federal Medicare populations
Domain
Healthcare administration / Medicare claims
Required skills
Clinical nursing judgment, medical policy interpretation, claims review, grievance/appeals investigation, written correspondence, regulatory compliance
Preferred skills
Home health/hospice claim review, MAS/CMS mainframe systems, surgical services/ICU experience, Part A Medicare experience
Technologies
MAS, CMS mainframe systems
Responsibilities
Conduct investigations and reviews of member and provider grievances and appeals; Assess necessity and reasonableness of billed items using medical policy; Generate written correspondence to providers, members, and regulatory entities; Ensure timely resolution of appeals and grievances.