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We are looking for a Utilization Review Nurse Remote/Local (Richardson, TX). The individual should be interested in non-direct patient care setting. Experience working within the workers compensation insurance/medical industry preferred.
The Utilization Review Nurse (UR Nurse) performs medical necessity review of proposed, concurrent, or retrospective clinical services for injured workers in conjunction with specific state jurisdictional requirements. The UR Nurse determines medical necessity of these services by utilizing clinical expertise, judgment, and established medical criteria. Performs quality assurance review of peer review reports, correspondences, addendums or supplemental reviews. We are looking for an individual who is seeking to be challenged, pays close attention to detail, able to work independently, is well versed with treatment guidelines, and is able to meet deadlines. Candidates should be a RN or LVN with experience in claims industry, specifically Workers Compensation, and possess a strong desire to learn and grow.
- 1-2 of related clinical nursing or case management experience
- Ability to learn quickly.
- Claims/Medical Terminology and Utilization Review/Peer Review background.
- Ability to research and document clearly.
- Excellent computer skills.
- Registered Nurse (RN)/Licensed Vocational Nurse (LVN)/PRN licensing required.
- Job skills must include excellent communication and grammar skills, critical thinking skills, and ability to manage time efficiently and meet stringent time frames.
- Review complex workers compensation medical treatment requests to ensure accordance with evidence based medical treatment guidelines, which are generally recognized by the national medical community and are scientifically based.
- Research claim file in relation to the requested medical treatment while interpreting medical reports/claims summaries and applies appropriate established guidelines to requested treatment. Refers treatment requests, which do not meet guidelines, for peer review and determination.
- Performs quality assurance of file reviews submitted by physician reviewers.
- Ensures clear, concise, evidence-based rationales have been provided in support of all recommendations and/or determinations
- Ensures that all client instructions and specifications have been followed and that all questions have been addressed
- Ensures each review is supported by clinical citations and references when applicable and verifies that all references cited are current and obtained from reputable medical journals and/or publications
- Ensures the content, format, and professional appearance of the reports are of the highest quality and in compliance with company standards
- Ensures reports meet state and federal medical necessity mandates, client specifications and company protocols.
- May evaluate physician specialty assignment and guidelines application based on work comp guidelines or assist in the analysis of peer reviews.
- Prepare and respond to client inquires, identifying areas for confirmation and clarity.
- Monitor file activity to ensure time requirements are met.
- Maintain records by reviewing notes; logging events and noting progress of work.
- Ability and confidence to speak with physicians and clients regarding the content of their medical peer reviews.
- Communicate inconsistencies and/or inaccuracies based on medical documentation and/or state guidelines.
- Improve team’s competence by providing resources; balancing file requirements within the client specifications all within company procedures and guidelines.
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The Director of Utilization Review oversees and develops clinical services including utilization review, peer reviews, case management and quality assurance. Director of UR manages day-to-day operations of all the Utilization Review nursing staff, intake and support staff.
– Supervision and development of UM nurses (remote and local), intake and support staff
– Reviewer coordination and relation.
– Scheduling, planning and delivery of services
– Delivery of quality of UR Services
– Maintains client contractual compliance and Utilization Review Accreditation Committee (URAC) compliance.
– Development processes, policies Procedures within the department
– Manages continuous improvement in the quality of care and service provided
– Review all reviews for appropriate documentation and turn-around time
– Responsible for reporting the appeal and denials and back up for the denial and appeal log
– Auditing denial/appeals and log on a monthly basis
– Make recommendations regarding: staffing, training, CEU opportunities and allocation of resources
– Annual performance evaluations of organizational staff
– Collaborates with other departments within the organization for ongoing collaboration
– Assist with delegation and resolution of complaints
– Assist with development and coordination of quality program
– Collaborates with other departments and serves as a liaison to improve communication and customer service
Job Requirements –
- Current RN/BSN/BA in Nursing and/or Business Healthcare Management
- At least 5 years experience in Utilization Management, Case Management and/or Quality Management
- CCM, ABQURARP or other UR designation preferred
- At least 5 years clinical experience
- PC literate, including Microsoft Office products
- Leadership/management/motivational skills
- Strong organizational skills
- Excellent interpersonal skills
- Excellent negotiation skills
- Ability to work in a team environment
- Ability to travel
- Ability to meet or exceed Performance Competencies
ezURs has an immediate need for part-time and full-time Certified Professional Medical Coders. Experience with HCC related activities and general auditing preferred. Ccertified coders will review, analyze, and code diagnostic information within a patient’s medical record based on client specific guidelines. Each coder will ensure compliance with established ICD-9 (and soon ICD-10), CM coding guidelines, third party reimbursement policies, regulations and accreditation guidelines. Opportunity to work from home.Competetive pay rate.
ACCEPTABLE CERTIFICATIONS INCLUDE:
CPC/CPC-A/COC(previously CPC-H)/CCS/CCS-P/RHIA(with 3-5 years of coding experience)/RHIT(3 years of coding experience)
REQUIRED EXPERIENCE AND SKILLS:
- Extensive knowledge of ICD-9 and CPT classifications and coding of diagnoses and procedures
- Clinical background preferred, but not required.
- Knowledge of and proven adherence to coding guidelines, Coding Clinic determinations, and CMS and other regulatory compliance guidelines and mandates.
- Strong computer experience in MS Word, Excel and Outlook
- In depth knowledge of medical terminology, human anatomy/physiology and pharmacology
- Strong communication skills
- Ability to multi-task and independently meet deadlines