Medical Review Nurse - Remote

Title: Medical Review Nurse - Remote

 

 

 

Mandatory skills:

 

Utilization Review,

Behavior Health, Registered Nurse,

Healthcare delivery system,

medical nursing practice, medical case management, quality management, prior authorization,

claim forms, UB claims, claims policies,

medical documentation, emergency criteria, medical necessity, revenue code,

CPT coding, HCPC coding, UR coding, ICD-9 coding,

Maternal and Child Health services, preventive health, family planning, sterilization, pregnancy termination,

EPSDT, Early and Periodic Screening Diagnosis and Treatment, LTC, long term care, acute, chronic long-term

 

Description:

 

The role will be focused on the review and adjudication of the client 1500 claim forms. Some coordination will be required with medical providers for 2nd level reviews and evaluating against prior authorizations and UB claims. The candidate will need a computer which client can set up remote desktop access. The role does not currently allow for Overtime but could be approved as the client has need.

 

Major duties and responsibilities include but are not limited to:

Performs medical claims review/adjudication using claims industry standards. Determines if a claim meets emergency criteria, medical necessity, and/or correct revenue code/CPT/HCPC coding. Also determines if the level of care and length of stay is appropriate for the client recipient.

Prepares reports and analyzes savings and trends. Interacts with other departments/providers as needed.

Performs special projects including but not limited to research projects.

 

Knowledge:

Medical nursing practice, medical case management protocols, quality management and utilization review protocols as related to all populations including Maternal and Child Health services, preventive health, family planning, sterilization, and pregnancy termination, EPSDT, acute, LTC, chronic long-term elderly and physical disabled, developmentally disabled, behavioral/mental health, and Tribal

Healthcare delivery system nationally and locally

Managed care processes

Acute nursing processes including assessment, planning, intervention, and evaluation

InterQual Criteria

CCI

Coding: CPT, HCPCS, ICD-9

Medical Claims Review

Statistical analysis

Computer data retrieval and input

Interpretation of governmental agencies

Client Rules and Regulations

Code of Federal Regulations

 

Requirements:

Active RN License in AZ

Behavior Health experience, (Outpatient preferably)

 

Skills:

Organizational skills that result in prioritization of multiple tasks

Interpretation of rules, laws and client policy pertaining to the client program

Good written and communication skills

Computer skills

Utilization Review skills

Medical Claims Review skills

Producing work products with limited supervision

Effectively collaborating with people in positions of all levels

Research and analysis

Team player and can work independently

 

Abilities:

Interpret and apply medical and claims policies

Read and interpret medical documentation

Evaluate medical documentation for emergency criteria, medical necessity, correct CPT coding

Determine appropriate hospital levels of care and lengths of stay

Respond to inquiries for UR/CPT coding decisions

Maintain data for monthly reports

Work independently with minimal supervision

Ability to work Virtually

 

Experience Requirements:

High school Diploma

Possession of a current license to practice as a registered nurse in AZ and experience in health care delivery systems.

 

Preferred:

Experience in concurrent and retrospective review; CCI, lnterQual, HCPCS and CPT Coding; managed care medical review experience. Certification in CPT Coding is a plus.

 

Notes:

 

8:00am- 5:00pm 40hrs per week, (M-F, no weekends. No OT time).

Remote

Primarily remote, however candidates may need to go onsite. Candidate may go onsite for training 1-2 times for training once starting position.

 

VIVA USA is an equal opportunity employer and is committed to maintaining a professional working environment that is free from discrimination and unlawful harassment. The Management, contractors, and staff of VIVA USA shall respect others without regard to race, sex, religion, age, color, creed, national or ethnic origin, physical, mental or sensory disability, marital status, sexual orientation, or status as a Vietnam-era, recently separated veteran, Active war time or campaign badge veteran, Armed forces service medal veteran, or disabled veteran. Please contact us at for any complaints, comments and suggestions.

 

 

Contact Details :

 

Account co-ordinator: Ramadas Kumaresan, Phone No: (847) 786-5904, Email: staffing10@viva-it.com

 

VIVA USA INC.

3601 Algonquin Road, Suite 425

Rolling Meadows, IL 60008