Retrospective Clinical Claims Review Nurse, RN (Remote)

Date: Aug 30, 2021

Location: Rancho Cucamonga, CA, US

Company: Inland Empire Health Plans

Job Requisition ID: 5603 


Position Summary/Position


Under the direction of the Long-Term Care Manager, the Retrospective Clinical Claims Nurse, RN is responsible for conducting timely medical reviews of IEHP facility and professional claims and appeals. The Retrospective Clinical Claims Review Nurse, RN will perform all reviews under the direction of the Long-Term Care Manager.  

Major Functions (Duties and Responsibilities)


1. Review medical records submitted with claims applying nationally recognized clinical criteria for in-patient medical necessity. Contractual agreements. Lines of business and departmental policies and procedures.
2. Act as the key clinical interface between Claims and Medical Services departments.
3. Attend UM and Claims team meetings.
4. Review inpatient claims that require authorization, appeals and other disputed claims in a timely manner to meet regulatory requirements.
5. Obtain the appropriate clinical information necessary to make authorization decisions for unauthorized claims.
6. Identify and track and trend potential denied services/admissions/days by LOB, contract. Facility and cost to present to the Utilization leadership including the Sr. Medical Director, and Clinical Directors both Plan and Direct, for appropriate decision/direction.
7. Review and identify medical records and claims to determine if charges and or services are billed appropriately. This includes reviewing CPT/HCPCS codes and up-coding practices.
8. Analyze Evaluation and Management codes, CPT and HCPCS, J codes etc. on out/ in patient claims for trending and appropriate billing practices and present findings to Sr/ UM management monthly with recommendations for improvement or intervention. Track and trend in billing patterns by provider and reports to the Manager practices that may need further investigation.
9. Develop and sustain positive working relationships, collaborating with physicians, nurses, ancillary personnel and all others as appropriate to promote open communication channels, obtain/disseminate information, and enhance customer relations.
10. Adapt to changes or unusual circumstances to promote cooperation and minimize disruption of working environment.

Supervisory Responsibilities

Leading: Self

Experience Qualifications


Two or more years managed care experience with inpatient and outpatient utilization and case management required.

Preferred Experience


Experience in reviewing inpatient medical records and claims preferred. Experience in managed care, MediCal, Medicare, and preferred.

Education Qualifications


High school diploma or GED required.

Preferred Education

Professional Certification

Professional Licenses


Possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California BRN required.

Drivers License Required

Yes, must have a valid California Driver's License.

Knowledge Requirement


CPT, ICD-9, HCPCS and hospital revenue codes. Nationally recognized clinical criteria (e.g. InterQual, Milliman, Apollo), MediCal, Medicare and other state/federal Program & Regulations.

Skills Requirement


Proficient in computer applications such as Word and Excel. Data Entry.

Abilities Requirement

Commitment to Team Culture


The IEHP Team environment requires a Team Member to participate in the IEHP Team Culture. A Team Member demonstrates support of the Culture by developing professional and effective working relationships that include elements of respect and cooperation with Team Members, Members and associates outside of our organization.

Working Conditions


While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; talk or hear; and taste or smell. The employee must occasionally lift or move up to 25 pounds. Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception and the ability to adjust focus.

Physical Requirements


Starting Salary: $75,296.00  - $95,992.00  

Pay rate will commensurate with experience


Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. We are also one of the largest employers in the region. With a provider network of more than 6,000 and a team of more than 2,000 employees, IEHP provides quality, accessible healthcare services to more than 1.2 million members. And our mission and core values help guide us in the development of innovative programs and the creation of an award winning workplace. As the healthcare landscape is transformed, we’re ready to make a difference today and in the years to come. Join our Team and Make a Difference with us! IEHP offers a Competitive salary and a benefit package with a value estimated at 35% of the annual salary, including medical, dental, vision, team bonus, and retirement plan.


Nearest Major Market: Riverside
Nearest Secondary Market: Los Angeles