Registered Nurse - Medical Review Specialist

ABOUT AVOSYS


Avosys is a growing integrator of professional, technological and management solutions services. Founded in 1998, Avosys provides services nationwide to Federal, Commercial, Local and State clients. We recognize the foundation of our firm is our people and we continue to rise above our competition by hiring the best.


DESCRIPTION


Is it your calling to serve our Nation's Heroes? Avosys is seeking a Registered Nurse - Medical Review Specialist to provide services to the military and their families.


EMPLOYMENT WITH AVOSYS

• Maximize family time with no weekend, Holiday, or on-call requirements
• Maintain work-life balance with guaranteed 8-hour shifts
• Achieve peace of mind with malpractice insurance provided at no cost

TITLE: Registered Nurse - Medical Review Specialist


LOCATION: Remote work from home.


HOURS: Monday thru Friday 8 hour shift with core hours between 8-2 CST 9-3 EST, no overtime is allowed.


SUMMARY:


Perform clinical reviews of Medicare Part A and Part B claims for Medical Review, Redeterminations/Appeals (Appeals), and Prior Authorization requests (collectively, the "Services") in accordance with CMS (Centers for Medicare & Medicaid Services) requirements.


QUALIFICATIONS:

• Minimum of two (2) years' clinical experience
• Active and current Registered Nurse license
• Bachelor's required
• Excellent written and oral communication skills
• Demonstrated experience with evaluating medical and health care delivery issues
• Strong computer skills to include Microsoft Office proficiency
• Preferred (but not required) qualifications:
• Insurance industry experience
• Oral and written English-Spanish bilingual skills

RESPONSIBILITIES: include, but not limited to:

1. Clinical review of services:
   • Review medical record documentation within CMS timeliness parameters (i.e., 20 days from receipt of the medical record for pre-payment reviews and 50 days from receipt of the medical record for post payment reviews).
   • Utilize the applicable Medicare policies (i.e., Local Coverage Determinations, National Coverage Determinations, Internet-Only Manual (IOM) citations, inpatient tools, etc.) to ensure the services comply with all Medicare regulations and documentation requirements.
   • Review documentation for medical necessity per guidelines outlined in the Social Security Act 1862(a)(1).
   • Ensure that all documentation includes a valid signature consistent with the signature requirements.
2. Documentation of rationale for processing decisions:
   • Provide a claim sample of three (3) claims to Companies via established protocols and timeliness parameters (i.e., 18 days from receipt of the medical record for pre-payment reviews and 48 days from receipt of the medical record for post payment reviews) for quality review prior to finalization of documentation of reason for payment, reduction, or denial of service to ensure accuracy of claim decision making.
   • Companies will review the three-claim sample for accuracy of claim decision and will make and return decisions to the MRS within 24 hours or less.
   • Complete the documentation of the reason for payment, reduction, or denial of service for all claims on an electronic decision template to be provided by Companies. This rationale must be in sentence format so that it may be inserted directly into the response to the provider, must be clear and well-written, and contain sufficient information to educate the providers on how the review decision was made.
   • Return documented decision electronically to Companies via established protocols and timeliness parameters (i.e., 20 days from receipt of the medical record for pre-payment reviews and 50 days from receipt of the medical record for payment reviews).
   • Complete the review results letter in the Companies' letter writing system within 35 days from receipt of the medical record for pre-payment reviews and no later than 60 days from receipt of the medical record for post payment reviews.
   • Document all case activity in Companies' provider tracking system on the day the activity occurs.
   • Complete one-on-one provider education (i.e., webinar, conference call, etc.) within 30 days of sending out review results letter.
   • Respond to provider inquiries related to case and/or claims throughout the course (i.e. in 24 hours or less) of review.
   • If additional clinical guidance is required, complete the Contractor Medical Director ("CMD") assistance form, track response, and update review accordingly.
   • Conduct telephone development for missing or additional records for easily curable errors.
   • Notate date of receipt of additional documentation received in the Companies' provider tracking system.
   • Upon request by Companies, initiate or participate in provider teaching activities, creating written teaching material, providing one-on-one education or education to a group as a result of an MR review.
   • If fraud activity is suspected, immediately complete initial referral packet for external entity referral and return the packet to the Companies.
   • Complete referrals to Companies' provider outreach and education ("POE") area in provider tracking system for cases that have a moderate or major error rate.
   • Lead and Alternate Lead will participate in all monthly departmental training and meetings, and all Staff will participate as requested.
   • Submit all cases for review and approval for quality and closure of cases.

Job responsibilities are subject to change to meet Military Treatment Facility requirements. Additional immunization record, security and background check requirements are also considered as qualifying criteria.


Position Type: Full Time


Location: Remote


Industry: Government Contracting


Shift: Day Business Hours


Travel: No


Salary: Based on Experience


Telework: Yes


Equal Opportunity Employer/Veterans/Disabled


All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, gender identity, national origin, or protected veteran status and will not be discriminated against on the basis of disability. If you are an individual with a disability and require a reasonable accommodation to complete any part of the application process, or are limited in the ability or unable to access or use this online application process and need an alternative method for applying, you may contact View phone number on click.appcast.io or View email address on click.appcast.io for assistance.