Medical Review 3

Talent Technical Services, Inc

🇺🇸 United States
On-site
Manager or above
11 hours ago
$50 – $52 / hour

DRG
CMS
RN License
EMR
Outlook

11 hours ago

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Description: Summary:
The Facility Compliance Review team reviews post service prepayment facility claims for contract compliance, industry billing standards, medical necessity and hospital acquired conditions/never events.. The Utilization Management Nurse, Senior will report to the Senior Manager, Facility Compliance Review. In this role you will be reviewing medical documents and applying clinical criteria to establish the most appropriate level of care. Also, you will be reviewing hospital itemized bills for a comprehensive line-by-line audit and manual claims processing on exceptions to ensure that appropriate billing practices are followed based on facility specific contract language. These exceptions may include medical necessity, DRG validation, stop loss, trauma, ER, burns, implants, NICU, transplants, hospital acquired conditions/never events and aberrant billing.

Your Work

In this role, you will:
•Perform retrospective utilization reviews and first level determination approvals for members using BSC evidenced based guidelines, policies and nationally recognized clinal criteria across lines of business or for a specific line of business such as Medicare and FEP
•Conducts clinical review of claims for medical necessity, coding accuracy, medical policy compliance and contract compliance
•Prepare and present cases to Medical Director (MD) for medical director oversight and necessity determination and communicate determinations to providers and/or members to in compliance with state, federal and accreditation requirements
•Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards and identify potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate
•Clearly communicates, is collaborative, while working effectively and efficiently
•Review itemizations for coding logic using industry standards as well as CMS guidelines
•Triages and prioritizes cases to meet required turn-around times
•Identifies potential quality of care issues, service or treatment delays as clinically appropriate.
•Clinical judgment and detailed knowledge of benefit plans used to complete review decisions

Qualifications:
•Requires a current California RN License
•Requires at least 5 years of prior relevant experience
•Requires independent motivation, strong work ethic and strong computer navigations skills
•Previous managed care experience including inpatient claims or concurrent review preferred

Custom Fields:
Name: calPERS
Value: No

Name: Interview Process
Value: Schedule for interview for 30 minutes to discuss the role and their experience.

Name: Potential to Convert to FTE?
Value: Yes, if funding is secured it could be turned into FTE

Name: Niche Skills
Value: None

Name: BSC Network Access
Value: Network Access

Name: Will this worker be working on VDI?
Value: No

Name: Software Skills Required
Value: •Requires independent motivation, strong work ethic and strong computer navigations skills
Previous EMR experience preferred
Microsoft Office including Teams, Outlook

Name: Is there a potential to extend past the original assignment duration?
Value: Yes

Name: Resource Type
Value: Staffing

Name: Preferred/nice to have skills
Value: •Requires independent motivation, strong work ethic and strong computer navigations skills
•Previous managed care experience including inpatient claims or concurrent review preferred

Name: Interview Method
Value: Video Interview

Name: Travel Required? If so, please elaborate
Value: No

Name: Would you be open to hiring workers outside of California in lower cost markets?
Value: No

Name: Company of Origin
Value: ***

Name: Number of Interviews
Value: 1

Name: Will this person be using VDI on their personal laptop instead of having a physical laptop issued from Cross?
Value: None

Name: Who will conduct interviews
Value: Anna Gunsser and Tara Brown

Name: Required Testing?
Value: No

Name: Top 3 Required Skills
Value: Previous UM/Managed Care Experience, Concurrent or post service inpatient review experience, CA RN Licensure

Name: Disqualifiers/Dislikes on Resumes
Value: N/A

Name: Required Certifications
Value: CA RN Licensure

Name: Education Requirements
Value: •Requires a bachelor's degree or equivalent experience
•Requires a current California RN License
•Requires at least 5 years of prior relevant experience

Name: Work Set up
Value: Remote

Name: CostCenterOU
Value: Healthcare Quality and Affordability

Name: Will this worker be supporting HMO or PPO?
Value: PPO

Medical Review 3 · Talent Technical Services, Inc

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