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Schedule: Mon. - Fri. 8:00am-4:30pm
This position may require some local travel.
The Nurse Reviewer complete authorizations and appeals on Medicaid accounts. This position requires critical thinking and judgment and must demonstrate the ability to appropriately use standard criteria established by state Medicaid programs or hospital policy. Audit and analysis must be accurate and consistently ensure a high level of quality, knowledge of laws, rules, regulations and guidelines necessary to ensure compliance and protection of information.
Primary / Essential Functions:
The Primary/ essential job duties may not be exhaustive.
* Performs audits of medical records to identify and/or defend charges, including:
* Defense Audits
* Stop-loss Audits
* Patient Inquiry Audits
* Charge Hold Audits
* Biller Requested Audits
* Become familiar with assigned facilities CDM and departmental charge protocol
* Organizes and prioritizes multiple cases concurrently to ensure departmental workflow and case resolution.
* Enter audit findings and/or data into Adreima's computer based system.
* Proficiently utilize multiple computer based systems to complete and document work
* Client based billing, Internal based billing, medical record and quality systems
* Microsoft Outlook, Word and Excel
* Function in a professional, efficient and positive manner
* Must be customer-service focused and exhibit professionalism, flexibility, dependability, desire to learn, commitment to excellence and commitment to profession
* Maintain confidentiality of patient information and abide by all HIPAA related guidelines
* Primary function will be retrospective reviews for any state requiring certification for billing purposes
* Provide clear and accurate documentation and coding of activities per guidelines established in client system and Adreima system
* Establish professional relationship as needed with State agencies, HMO's, clients and any other entities involved in executing duties
* Provide support and consultation to Disability/Eligibility team for review of Medical Record to determine eligibility
* Will provide and participate in cross training activities as needed
3-5 years experience in Nursing.
RN or LPN required