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Clinical Review Nurse

Clinical Review Nurse

Fully Remote Remote Worker

Job Type

Full-time

Description

Valenz Health simplifies the complexities of self-insurance for employers through a steadfast commitment to data transparency and decision enablement powered by its Healthcare Ecosystem Optimization Platform. Offering a strong foundation with deep roots in clinical and member advocacy, alongside decades of expertise in claim reimbursement and payment validity, integrity, and accuracy, as well as a suite of risk affinity solutions, Valenz optimizes healthcare for the provider, payer, plan, and member. By establishing true transparency and offering data-driven solutions that improve cost, quality, and outcomes for employers and their members, Valenz engages early and often for smarter, better, faster healthcare.

About Our Opportunity

As a Clinical Review Nurse for our Bill Review team, you will pre-screen claims to ensure that services rendered are medically necessary and appropriate. Every day, you will audit claims identifying clinical errors, overpayments, and/or experimental and investigational items based on accepted billing and plan policy exclusions and share findings with our negotiation team.

Things You’ll Do Here:

  • Identify correct billing and savings on claims by running the codes through programs.
  • Collaborate with the Negotiation team to resolve claim issues and obtain savings by applying corrected claims, letters of agreement, or other documentation necessary.
  • Finalize IRO (Independent Review Organization) savings by identifying savings, requesting plan documents, medical records, create submission, finalize report.
  • Participate in client review calls acting as a Subject Matter Expert in the clinical bill review space.
  • Evaluate and respond to bill reconsideration requests.
  • Maintains a consistent department bill review prescreen turnaround time. Standard TAT for Bill Review pre-screen 24 hours from UB/IB receipt.
  • Partners with peers and management in the formulation and documentation of department processes and policies, interdepartmental resolutions, and system improvements.
  • Assists direct supervisor in achievement of departmental goals and suggestions that will increase revenue relating to Bill Review.
  • Complies with/supports HIPAA standards.

Reasonable accommodation may be made to enable individuals with disabilities to perform essential duties.

What You’ll Bring to the Team:

  • 3+ years of experience in auditing, claims, bill review, or case management.
  • 2+ years of experience in a clinical setting in medical surgical, critical care, or equivalent.
  • Current BSN, RN, or MSN.
  • Working knowledge of industry coding and guidelines, ICD-10, CPT, HCPCS and Revenue codes, CMS guidelines, etc.
  • Strong aptitude for relationship building with a highly effective communication style.

A plus if you have:

  • Experience with RevCycle Pro/or Encoder Pro/or SuperCoder.
  • Knowledge of Investigative /Experimental reviews, HCD, implant repricing, level of care reviews, DRG reviews.
  • CPC or CIC Certification
  • Health insurance experience

Where You’ll Work

This role is remote.

Why You Will Love Working Here

We offer employee perks that go beyond standard benefits and compensation packages see below!

At Valenz, our team is committed to delivering on our promise to engage early and often for smarter, better, faster healthcare. We want everyone engaged within our ecosystem to be strong, vigorous, and healthy. You’ll find limitless growth opportunities as we grow together. If you’re ready to utilize your skills and passion to make a significant impact in the healthcare self-funded space, Valenz might be the perfect place for you!

Perks and Benefits

  • Generously subsidized company-sponsored medical, dental, and vision insurance
  • Company-funded HRA
  • 401K with company match and immediate vesting
  • Flexible working environment
  • Generous Paid Time Off
  • Paid maternity and paternity leave
  • Paid company holidays
  • Community giveback opportunities, including paid time off for philanthropic endeavors

At Valenz, we celebrate, support, and thrive on inclusion, for the benefit of our associates, our partners, and our products. Valenz is committed to the principle of equal employment opportunity for all associates and to providing associates with a work environment free of discrimination and harassment. All employment decisions at Valenz are based on business needs, job requirements, and individual qualifications, without regard to race, color, religion or belief, national, social, or ethnic origin, sex (including pregnancy), age, physical, mental or sensory disability, HIV Status, sexual orientation, gender identity and/or expression, marital, civil union or domestic partnership status, past or present military service, family medical history or genetic information, family or parental status, or any other status protected by the laws or regulations in the locations where we operate. We will not tolerate discrimination or harassment based on any of these characteristics.