GuideWell Source

This position is responsible for maintaining the integrity of Medicare Part A and B provider files by reviewing applications for regulatory compliance. Responsibilities include validating provider information, establishing electronic funds transfers, and responding to enrollment inquiries.

The role involves responding to Medicare Part A and B inquiries from providers regarding coverage, billing, and appeals. Responsibilities also include researching complex claim issues and educating customers on Medicare policies and self-service tools.

The Clinical Review Nurse evaluates health claims for medical necessity and appropriateness based on national and local policies. They also identify provider issues and conduct educational outreach to ensure compliance with healthcare standards.