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Claims Clinical Reviewer (myNEXUS)

Location: Springfield, MO
Company: Anthem, Inc
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Description
SHIFT: Day Job
SCHEDULE: Full-time
Your Talent. Our Vision. At myNEXUS, a proud member of the Anthem, Inc. family of companies, it's a powerful combination. It's the foundation upon which we're creating greater access to care for our members, greater value for our customers and greater health for our communities. Join us and together we will drive the future of health care.
myNEXUS is a technology-driven, care and benefit management service that enables individuals to live healthier lives in their homes. Our proven clinical model connects individuals to intelligent care delivering independence at lower costs. To maximize health delivery, we consistently leverage our: Innovative Technologies, Advanced Clinical Expertise, and Proprietary Network Engagement Platform. We are continuously pioneering ways to optimize health resources for our clients and their customers. Through our proprietary network management and engagement programs, we realize enhancements in quality, outcomes, and care effectiveness.
Job Summary:
The Pre-Payment Clinical Reviewer will be primarily responsible for conducting post-service, pre-payment claim reviews based on CMS and myNEXUS requirements for proper documentation, billing and coding rules, and screening for additional clinical review
DUTIES AND RESPONSIBILITIES:
- Complete pre-billing validation activities to ensure submitted claims for payment meet regulatory requirements to ensure the provider, home health agency, or service provider organization appropriately bills for services delivered in a timely manner for payor
- Perform claim review within the myNEXUS Claims System to determine readiness for adjudication for individual provider claims submissions.
- Screen and validate proper clinical and non-clinical documentation has been submitted in preparation for claims adjudication in the myNEXUS Clinical Decision Support System, to include: Face - to-Face, SOC OASIS, ROC OASIS, Re-Cert OASIS, Signed Plan of Care (485), NOMNC, W-9, HIPPS Code, and Visit Notes.
- Performs telephonic and electronic provider outreach for missing requested, clinical and non-clinical documentation
- Publish electronic daily reports to validate submitted, client claim readiness for adjudication to internal myNEXUS teams.
- Verify submitted physician orders and other submitted provider clinical documentation with requested services and visits match actual visits and services performed by home health care agencies.
- Upon receipt and validation of the complete clinical and non-clinical documentation, colleague reviews then assemble information package for transmission to the myNEXUS PSCCR Team for clinical review.
- Assesses the necessity and reasonableness of the clinical and non-clinical documentation items supplied to support a clean claim submission using myNEXUS policies and other materials
- Collaborate with the Claims Department Management Team on regarding questions with the claims submission and claims billing process.
- Accepts additional assignments willingly.
Professional Requirements:
- Completes all compliance related training and demonstrates compliance on the job; completes all annual training requirements
- Adheres to all company policies
- Maintains confidentiality of all private information related to patients or employees.
- Attends meetings, prepared and participates accordingly
- Represents the organization in a positive and professional manner
- Performs other duties as assigned
- Actively participates in performance improvement and continuous quality improvement (CQI) activities.
- Complies with all organizational policies regarding ethical business practices
- Communicates and demonstrates the mission, ethics and goals of the facility, as well as the focus statement of the department.
Job Requirements
Required Skills/Abilities:
- Ability to read and communicate effectively in English
- Additional languages preferred
- Basic computer knowledge such as Word and Excel
- Excellent customer service and follow-up skills
- Ability to sit for long periods and read monitor
- Strong attention to detail
- Familiarity with Home Health documentation and billing practices desired
Education and Experience: Bachelor's degree required; Master's degree preferred.
- Registered Nurse; minimum of 2 years of experience in a variety of healthcare settings
- Home Health experience preferred
- Current state register RN License
Anthem, Inc. has been named as a Fortune 100 Best Companies to Work For® , is ranked as one of the 2020 World's Most Admired Companies among health insurers by Fortune magazine, and a 2020 America's Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran. Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions.
REQNUMBER: PS49971
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