Medical Review Nurse
The Medical Review Nurse reviews fee-for-service (FFS) records to determine if services billed were medically necessary under the Medicaid and Children's Health Insurance Program (CHIP) for the Payment Error Rate Measurement (PERM) program.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Essential duties and responsibilities include the following. Other duties may be assigned.
Responsible for the integration of CNI Core Competencies into daily functions, including: commitment to integrity, knowledge / quality of work, supporting financial goals of the company, initiative / motivation, cooperation / relationships, problem analysis / discretion, accomplishing goals through organization, positive oral / written communication skills, leadership abilities, commitment to Affirmative Action, reliability / dependability, flexibility and ownership / accountability of actions taken.
Performs second level Inter-rater Reliability (IRR) and Difference Resolution (DR) reviews as needed.
Understands and abides by information technology security and Health Insurance Portability and Accountability Act (HIPAA) policies for dealing with Personal Health Information and Personally Identifying Information.
Reviews medical records to determine if the services identified were medically necessary in accordance with the state policies and federal regulations.
Documents review findings in automated system.
Works collaboratively with the Policy team to research and track new regulations relevant to the reviews.
Keeps Medical Review Manager informed of medical review status.
May be required to travel up to 10% of the time.
Responsible for aiding in own self-development by being available and receptive to all training made available by the company.
Plans daily activities within the guidelines of company policy, job description and supervisor’s instruction in such a way as to maximize personal output.
Responsible for keeping own immediate work area in a neat and orderly condition to ensure safety of self and coworkers. Will report any unsafe conditions and/or practices to the appropriate supervisor and human resources. Will immediately correct any unsafe conditions to the best of own ability.
EDUCATION / EXPERIENCE
Bachelor's degree and a minimum of three (3) years relevant experience, or equivalent combination of education / experience.
Medical review experience in a clinical setting evaluating medical necessity of services, diagnosis and procedure coding. Minimum of three years’ experience as a Registered Nurse. Experience working in utilization review firm, or other health care claims processing organization involving medical and coding reviews of a variety of medical and surgical claims from a variety of provider types is preferred.
CERTIFICATES / LICENSES / REGISTRATION
Must be a Registered Nurse in one or more of the 50 states or D.C. with an active license
JOB SPECIFIC KNOWLEDGE / SKILLS / ABILITIES
Considerable program knowledge and understanding of Medicaid and CHIP principles and practices
Basic knowledge and understanding of medical coding rules and guidelines
Operational knowledge of computers with skilled proficiency in the use of Microsoft Office Suite and the ability to quickly grasp customized software systems
Solid organizational skills relevant to carrying out day-to-day responsibilities
Ability to manage multiple projects and priorities and to meet specified deadlines
Proficient in verbal, written and listening skills
Excellent customer service and relationship-building skills
Ability to interact and communicate with all levels of staff and management
Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference and volume. Ability to apply concepts of basic algebra and geometry.
Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public.