RN Claims Review

The Medical Claim Review Nurse provides a variety of services with respect to medical care review, cost containment, claims review, appeals and grievances, and analytical reporting. As part of our Claims Team, the MCR Nurse employs best practices and principles to ensure high quality and cost-effective assurance standards.

What You Will Do:

• Conducts retrospective case reviews for appropriateness/quality of treatment and bill accordingly, as well as medical
• Provides statistical case reviews and generates utilization reports
• Examine DRG pre-certification, certification of admissions, and continued stay.
• Act as a liaison between Medical and Claims departments regarding medical review issues.
• Communicate with other departments and personnel to facilitate proper adjudication of claims.
• Review medical information from various facilities for medical necessity.
• Maintain medical standards for all clients.
• Communication with hospitals, physicians, and subscribers regarding certification of hospital admissions and outpatient services.
• Meets with Management team about current processes and implementing new processes
• Develops relationships with physicians, healthcare service providers, and internal and external customers to help improve health outcomes for members.
• May access and consult with peer clinical reviewers, Medical Directors and/or delegated clinical reviewers to help ensure medically appropriate, quality, cost effective care throughout the medical management process.
• Educates the member about plan benefits and contracted physicians, facilities and healthcare providers.
• Refers treatment plans/plan of care to peer clinical reviewers in accordance with established criteria/guidelines and does not issue medical necessity non-certifications.
• Maintains compliancy with regulation changes affecting utilization management.
• Reviews patients’ records and evaluates patient progress.
• Documents review information in computer. Communicates results to the appropriate parties and enters the appropriate billing information for services.
• Responds to complaints per UR guidelines.
• Records and reports all information within scope of authority
• Performs analytical reporting from a variety of reports, client charts and other documents and participates in developing strategies for medical cost containment, maintaining quality of care and client satisfaction.
• Develop recommendations for appropriate solutions.
• Validate and perform quality assurance.
• Create or revise analytical approaches to reflect current priorities and circumstances.
• Develop, analyze, and implement project plans. Mobilize project teams.
• Exercise discretion, tact, and judgment when working with internal and/or external departments
• Develop plans or proposals that include cost/benefit analysis, policy, and financial, operational, and organizational implications.

You Will Be Successful If:

• Excellent communication skills, both verbally and in writing are critical.
• Knowledge of principles, practices and current trends in nursing as well as best practices in quality assurance.
• Knowledge and application of state and federal laws, statutes, and regulations; excellent analytical skills; ability to work as part of a team and be self-directed; and intermediate knowledge of Word and Excel.
• Communication qualifications include demonstrated verbal and written communication skills and ability to present information effectively, tailor presentations to a wide variety of audiences (including executive management), present complex concepts and recommendations clearly for management decision-making purposes.
• Ability to comprehend, interprets, and applies Business Rules Management System (BRMS) policies; ability to continually adjust in a dynamic environment; and ability to work as a member of a team.

What You Will Bring:

• 2 years of acute clinical experience
• Active RN License 
• One year of case management or utilization review experience

About Impresiv Health:

Impresiv Health is a healthcare consulting partner specializing in clinical & operations management, enterprise project management, professional services, and software consulting services. We help our clients increase operational efficiency by delivering innovative solutions to solve their most complex business challenges. Our approach is and has always been simple. First, think and act like the customers who need us, and most importantly, deliver what larger organizations cannot do – provide tangible results that add immediate value, at a rate that cannot be beaten. Your success matters, and we know it.

That’s Impresiv!