Entry Level Registered Nurse
To perform detailed case-by-case analysis of Coverage Determination and Redetermination transactions to identify those cases where adequate outreach to prescribing physician was not performed, and
To minimize the volume of cases requiring detailed case-by-case analysis by applying analytics to the data to identify those cases where adequate outreach to prescribing physical was not performed.
* Medicare Regulations related to Adequate Provider Outreach
* Internal Policy related to Provider Outreach
* PHI Handling
* PA Logic Training (Coverage Determination system of record)
* CCMS Training (Redetermination system of record - historical)
* Updating Records in Database
OVERVIEW OF ROLE:
o Provide backlog of support in possibly reviewing medical files for compliance
o Auditing patient medical charts and/or claims
o Ensuring all required legal transactions are in compliance
o If gap on required transactions will complete and process to adhere so that legal compliance is met
o Need strong analytical skills with attention to detail and good problem solving skills
o Accurately review documentation to make redetermination decisions
o Respond to client regarding work load assigned in a professional, timely and accurate manner
o Research and identify claims processing issues
o This is 2 to 3month project working minimum of 8 hours 5 days a week. Possible flexibility on work hours. Reliable and dependable must be able to start and complete project.
o Nursing program graduates pending RN License and/or Pharmacy Technical with or w/o CPhT License
o Prefer minimum 0 to 2years of experience in out-patient environment (non-clinical)
o Good Understanding of US Healthcare (Medicare)
Must possess strong analytical and attention to detail. Ability to work with on-site at Aliso Viejo worksite location.