Medical Claims Review Nurse

HMA is one of the nation's largest administrators of high-quality, innovative, and affordable health plans and distinctive services for self-funded organizations. Employers trust HMA's team of caring experts to protect two of their most important assets; their people and their health plan dollars.
In 2021, HMA was chosen as a Washington's Best Workplaces by our Staff and PSBJ™. Our vision, 'Proving What's Possible in Healthcare ® ,' and our values, People First!, Be Extraordinary, Work Courageously, Own It, and Win Together, shape our culture, influence our decisions, and drive our results.
What we are looking for: We are looking to hire people that care deeply about others, thrive in evolving environments, gain satisfaction from being part of a team and helping others succeed, are motivated by tackling complex challenges, are courageous enough to share ideas, are action-oriented, are resilient, and are results-driven.
What you can expect: You can expect an inclusive, flexible, and fun culture, comprehensive salary, benefits, and time off packages with plenty of personal development and growth opportunities. If you are looking for meaningful work, a clear purpose, high standards, work/life balance, and the ability to contribute to something important, find out more about us at: https://www.accesshma.com/
How YOU will make a Difference:
The Medical Claims Review Nurse provides monitoring of member utilization and claim patterns using clinical nursing knowledge and coding expertise to oversee the accuracy of claims for medically necessary care provided to our members. This work promotes the integrity of claim payment to support fiscal responsibility of payments. This nurse also works in conjunction with the Appeals team providing clinical expertise and performs high-level writing skills.
What you will do:

• Analyzes claims against clinical documentation using coding and clinical expertise
• Clinical support of the Hospital Bill Review process
• Retrospective utilization management case review
• Extrapolates and summarizes medical information for medical director and other external entities
• Ensures that reviews and appeals are resolved timely to meet regulatory timeframes
• Generates written correspondence to providers, members, brokers and clients

Knowledge, Experience, and Key Attributes needed for Success:

• Current Baccalaureate prepared (Preferred)
• Active RN clinical license
• Current Certified Professional Coder certificate (preferred)
• Experience in the application of common coding and billing standards including the American Medical Association CPT (Current Procedural Terminology), the Centers for Medicare and Medicaid Services National Correct Coding Initiative, Optum Coding resource manuals, the UB04 Billing Manual coding guidelines and the National Uniform Billing Committee
• 2+ years of clinical nursing experience
• Knowledge of Utilization Review processes
• Knowledge of the medical plan appeal process (preferred)
• Strong experience in clinical practice with diverse diagnoses
• Problem solving and critical thinking skills
• Excellent verbal and written communication skills
• Proficiency with Microsoft Office applications (Outlook, Word, DOSS)
• Ability to be self-motivated and self-directed
• Enjoys the pace and rhythm of a deadline-oriented environment with strong prioritization skills
• Behavioral health experience (Preferred)

How we Support your Work, Life, and Wellness Goals
We offer a comprehensive total rewards package including: competitive pay; annual incentive; medical, dental, and vision insurance; 401K retirement plan with match; generous PTO and holidays; an onsite gym facility; a gym subsidy; Life, AD&D, Short-Term and Long-Term Disability Insurances; an Employee Assistance Plan; free parking and easy freeway access to I-405 and I-520; a well-stocked kitchen on-site with subsidized snacks and refreshments; year-round wellness activities; the ability to earn a $500 wellness incentive; monthly events; paid volunteer hours and more!
HMA requires a background screen prior to employment.
Protected Health Information (PHI) Access Healthcare Management Administrators (HMA) employees may encounter protected health information (PHI) in the regular course of their work. All PHI shall be used and disclosed on a need-to-know-basis and according to HMA's standard policies and procedures.
HMA is an Equal Opportunity Employer