Professional Review Nurse

Professional Review Nurse

The Professional Review Nurse provides analysis of medical services to determine appropriateness of charges on multiple types of medical bills and review of medical reports to determine appropriateness of medical care. This is a remote position in CA.

Essential Functions & Responsibilities:

• Identify the necessity of the review process and communicate any specific issues of concern to the claims examiner/client and/or direct reporting manager
• Collect supporting data and analyze information to make decisions regarding appropriateness of billing, delivery of care and treatment plans
• Utilize clinical and/or technical expertise to address the provision of medical care and identify inappropriate billing practices and errors, such as: duplicate billing, unbundling of charges, services not rendered, mathematical and data entry errors, undocumented services, reusable instrumentation, unused services and supplies, unrelated and/or separated charges, quantity and time increment discrepancies, inconsistencies with diagnosis, treatment frequency and duration of care, DRG validation, service/treatment vs. scope of discipline, use of appropriate billing protocols, etc.
• Document work and final conclusions in designated computer program
• Additional duties as assigned

Knowledge & Skills:

• Concise and effective verbal and written communication skills
• Ability to interface with claims adjusters, attorneys, physicians and their representatives, advisors/clients, and co-workers
• Ability to effectively promote all Professional Review products with attorneys, claims examiners, customers and management
• Strong ability to effectively negotiate provider fees
• Must be proficient with Microsoft Office applications
• Knowledge of worker's compensation claims preferred

Education & Experience:

• Must maintain current licensure as a Registered Nurse in the state of employment with a minimum of 4 years clinical experience
• A minimum of an Associate Degree in Nursing as well as have a thorough knowledge of both C.P.T. and I.C.D.9 codes preferred
• Medical bill auditing experience preferred
• Experience in the clinical areas of O.R., I.C.U., C.C.U., E.R., and orthopedics preferred
• Prospective, concurrent and retrospective utilization review experience preferred

Pay Range: $70,304 – $85,473

CorVel uses a market based approach to pay and our salary ranges may vary depending on your location. Pay rates are established taking into account the following factors: federal, state, and local minimum wage requirements, the geographic location differential, job-related skills, experience, qualifications, internal employee equity, and market conditions. Our ranges may be modified at any time.

For leveled roles (I, II, III, Senior, Lead, etc.) new hires may be slotted into a different level, either up or down, based on assessment during interview process taking into consideration experience, qualifications, and overall fit for the role. The level may impact the salary range and these adjustments would be clarified during the offer process.

A comprehensive benefits package is available for full-time regular employees and includes Medical (HDHP) w/Pharmacy, Dental, Vision, Long Term Disability, Health Savings Account, Flexible Spending Account Options, Life Insurance, Accident Insurance, Critical Illness Insurance, Pre-paid Legal Insurance, Parking and Transit FSA accounts, 401K, ROTH 401K, and paid time off.

CorVel is an Equal Opportunity Employer, drug free workplace, and complies with ADA regulations as applicable.