Registered Nurse V
Remote in California
Mon to Fri, 08:00 AM-4:30 PM
3+ Months Potential to extend depending on the business needs or performance.

Summary
Federal Employee Program (FEP) Post Service Clinical Review RN - Ensures timely and accurate
clinical claim review of designated healthcare services. Post Service Clinical Review RN preforms
first level determination approvals for members using FEP and BSC evidenced based guidelines, policies and nationally recognized clinical criteria across lines of business or for a specific line of business. Successful RN candidate review post service clinical claim review requests for benefits, medical necessity, coding accuracy and medical policy compliance. Clinical judgment and detailed knowledge of benefit plans used to complete review decisions is required.

Essential Responsibilities:

• Ensures proper procedure and diagnosis codes is reviewed for submitted procedures/claims.
• Solicits support from SME's, leads and managers as appropriate
• Triages and prioritizes cases to meet required turn-around times
• Expedites access to appropriate care for members with urgent needs
• Prepares and submits clinical review cases to Medical Director (MD) for medical director
• oversight and necessity determination
• Communicate determinations to providers and/or members to in compliance with state, federal and
• accreditation requirements
• Develops and reviews member centered documentation and correspondence reflecting determinations
• in compliance with regulatory and accreditation standards
• Identifies potential quality of care issues, service or treatment delays and intervenes or as
• clinically appropriate
• Provides referrals to Case Management, Disease Management, Appeals and Grievance and Quality
• Departments as necessary
• Assists in the development and implementation of a proactive approach to improve and standardize
• overall retro claims review for clinical perspectives. Other duties as assigned.

General Knowledge & Experience Required:

• Current CA RN License.
• Bachelors of Science in Nursing or advanced degree preferred
• Requires practical knowledge of job area typically obtained through advanced education combined with experience.
• Typically, requires a college degree or equivalent experience and 3 years of prior relevant experience.
• Knowledge of CPT-4, ICD-10, HCPCs and provider billing practices.
• Demonstrate the ability to act independently using sound clinical judgement.
• Experience in a fast paced, production and quality environment preferred.
• Demonstrated efficient, time management techniques and skills.
• Able to handle multiple tasks simultaneously while prioritizing cases to meet regulatory and business based turn around times.

 
 
At SPECTRAFORCE, we are committed to maintaining a workplace that ensures fair compensation and wage transparency in adherence with all applicable state and local laws. This position’s starting pay is: $ 54.22/hr.