Posted in Legal 30+ days ago.
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Location: Tampa, Florida
The SIU Clinical Nurse provides subject matter and clinical expertise to all investigators and analysts within the SIU, reviewing and analyzing medical records and medical coding and rendering and supporting professional recommendations in connection with SIU investigations. The SIU Clinical Nurse conducts medical investigations, especially those presenting complex issues of medical necessity. The SIU Clinical Nurse works with company medical director personnel and others to develop and advance anti-fraud, waste, and abuse initiatives.
Education: High school diploma required; bachelor's degree or equivalent substantial work experience required.
Experience: At least five years of experience working as a registered nurse analyzing medical records and making medical necessity, authorization, or utilization decisions. Prior investigative experience or equivalent (legal services) preferred. Health insurance industry experience preferred. Knowledge of and experience working with government-funded health programs preferred.
Licenses/Certifications: Registered Nurse and Certified Professional Coder required. If candidate does not hold CPC credential, candidate will be required to obtain CPC credential within the first 12 months of employment.
Special Skills (e.g. 2nd language): Knowledge and understanding of claims processing systems, medical claims coding, and medical record documentation.
Technical Skills/Requirements: Basic personal computer skills necessary to navigate the MS-Windows operating system, Internet, health care claim systems, and other applications, is required. Ability to work effectively with Microsoft Office including Word, Excel, Outlook, Access, PowerPoint.