Review and Evaluation Nurse

Job Opportunity

Review and evaluate the medical necessity, appropriateness, quality, quantity, adequacy, and compensability of medical care and services rendered by Hospice providers under the Medical Assistance Program. The nurse is responsible for the review and evaluation of medical information and examination of medical records and other documentation to assure that eligible medical assistance recipients receive appropriate and quality medical care. The Medical Assistance Program must be properly billed, and that the provider and/or recipient fraud, abuse, and waste is detected. Requirements include the ability to prepare correspondence and reports, comprehend and apply regulations, policies, and standards, establish and maintain effective working relationships, carry out instructions and complete assignments, conduct field work, desk, and telephone reviews, travel to facilities/provider sites to conduct reviews and attend training and meetings as required across the state (includes overnight stays), communicate effectively (verbally and in writing) with coworkers, management, Office of General Council, other agencies, facility staff, and other medical assistance providers to review and discuss cases, enter essential data into the computer, physically traverse stairs, lift laptop, printer, and related equipment, walk long distances, and sit for long periods of time. Review and evaluate provider documentation to determine compliance with Medical Assistance regulations. Testify at administrative/legal hearings and to defend Department decisions. Maintain discretion and confidentiality.

Minimum Qualifications and Education Requirements: Registered Nurse