Aetna Medical Review Coord in Tampa, Florida

Req ID: 49511BR

POSITION SUMMARY

Applies clinical knowledge to assess medical bills against medical records to ensure appropriateness of treatment and level of service in Workers Compensation cases requiring retrospective review. Responsible for reviewing and analyzing information to make payment determinations based on established policies and guidelines and integrated evaluation of specific billing circumstances

Fundamental Components:

  • Retrospective medical review based on clinical coding logic in the Workers' Compensation bill review platform.

  • Conducts medical reviews of individual providers and hospital bills for coding and billing accuracy based on review of documentation.

  • Evaluates diagnostic testing of inpatient and outpatient services.

BACKGROUND/EXPERIENCE desired:

  • RN or LPN/LVN with current unrestricted state licensure required.

  • 3-5 years clinical experience in orthopedics, neurology, surgical, emergency room or ICU preferred.

  • Experience working with ICD-9, ICD-10, CPT-4, DRGs and HCPCS coding logic required.

  • Previous experience in claims review, workers compensation, case management, utilization review preferred.

  • Strong verbal and written communication skills

  • Working knowledge of Microsoft office programs: Outlook, Excel, Word

  • Effective analytical and problem-solving skills; ability to make some independent decisions

EDUCATION

The highest level of education required for candidates in this position is a Associate's degree or equivalent experience.

LICENSES AND CERTIFICATIONS

Nursing/Registered Nurse is required

Nursing/Licensed Practical Nurse is required

Medical Management/ is desired

Claims/ is desired

FUNCTIONAL EXPERIENCES

Functional - Nursing/Medical-Surgical Care/4-6 Years

Functional - Claims//1-3 Years

Functional - Clinical / Medical/Clinical claim review & coding/4-6 Years

Functional - Nursing/Case Management/4-6 Years

TECHNOLOGY EXPERIENCES

Technical - Aetna Applications//1-3 Years/End User

Technical - Remote Access//1-3 Years/End User

Technical - Desktop Tools//1-3 Years/End User

Telework Specifications:

Full-Time Telework (WAH)

Must live in the area surrounding Tampa, FL

ADDITIONAL JOB INFORMATION

Opportunity for an experienced Workers' Compensation Nurse to utilize their skills and develop a greater knowledge of coding and billing logic.

Aetna is about more than just doing a job. This is our opportunity to re-shape healthcare for America and across the globe. We are developing solutions to improve the quality and affordability of healthcare. What we do will benefit generations to come.

We care about each other, our customers and our communities. We are inspired to make a difference, and we are committed to integrity and excellence.

Together we will empower people to live healthier lives.

Aetna is an equal opportunity & affirmative action employer. All qualified applicants will receive consideration for employment regardless of personal characteristics or status. We take affirmative action to recruit, select and develop women, people of color, veterans and individuals with disabilities.

We are a company built on excellence. We have a culture that values growth, achievement and diversity and a workplace where your voice can be heard.

Job Function: Workers' Compensation