The Clinical Review Nurse is responsible for reviewing and making medical determinations as to the validity of health claims and levels of payment in meeting national and local policies as well as accepted medical standards of care. The incumbent applies clinical knowledge to assess the medical necessity, level of services and appropriateness of care which may include cases requiring prior authorization, complex pre-payment medical review or post-payment medical review.
ESSENTIAL DUTIES & RESPONSIBILITIES
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This list of essential job functions is not exhaustive and may be supplemented as necessary.
Review and analyze pre and post pay complex health care claims from a medical perspective:
• Perform clinical review work as assigned; may provide guidance to other team members and accurately
interpret and apply broad CMS guidelines to specific and highly variable situations.
• Conduct review of claim data and medical records to make clinical decisions on the coverage, medical
necessity, utilization and appropriateness of care per national and local policies, as well as accepted
medical standards of care.
• Review provider practices and identify issues of concern, overpayment and need for corrective action as
necessary; includes surfacing potential fraud and abuse or practice concerns.
• May develop recommendations for further corrective action based on medical review findings.
• May refer for review, or implement, corrective action related to medical review activities.
• May process claims and complete project work in the appropriate computer system(s).
Identify providers needing education and individually educate providers who are subject to medical
review processes:
• 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 (e.g., probe, progressive corrective action, consent, etc.) or appeal.
• This may involve discussion with CMS leaders and leaders in the provider community.
• Participate in special projects as assigned.
Performs other duties as the supervisor may, from time to time, deem necessary.
REQUIRED QUALIFICATIONS
• Nursing education diploma
• 2 years’ clinical experience
Utilization review experience
• Excellent written and oral communication skills
• Demonstrated experience with evaluating medical and health care delivery issues
• Strong computer skills to include Microsoft Office proficiency
*Remote position**
• Active and current Registered Nurse license
PREFERRED QUALIFICATIONS
Knowledge, Skill, Education/Training and Experience Requirement. (List the KSEs that would be a plus for the incumbent to have, however, are not required to successfully perform the job duties and responsibilities.
Certifications, Licenses, Registrations (List the credentials that are preferred for this role; i.e. RN
Insurance industry experience
Oral and written Spanish multi-lingual skills