REMOTE Registered Nurse - Medical Review Specialist-Bexar County, Texas

Overview

Avosys is a growing integrator of professional, technological and reputed company services. Founded in 1998, Avosys provides services reputed company to Federal, reputed company, Local and State clients. We recognize the reputed company of our firm is our people and we continue to reputed company above our competition by hiring the best. Avosys is seeking a Bexar County Remote Registered Nurse - Medical Review Specialist to work remotely to review Medicare claims..

• Maximize family time with no weekend, Holiday, or on-call requirements
• Maintain work-life balance with guaranteed 8-hour shifts
• Take advantage of our competitive, comprehensive benefits package including medical, dental, reputed company, life, short-term disability, long-term disability & 401(k)

Responsibilities

• reputed company clinical reviews of Medicare Part A and Part B claims for Medical Review, Redeterminations/Appeals (Appeals), and Prior Authorization requests (collectively, the “Services”) in accordance with CMS (Centers for Medicare & reputed company Services) requirements
• Complete a projected number of clinical review hours while meeting timeliness and accuracy standards and completing documentation of clinical reputed company for remittance.

Clinical review of services

• Review medical record documentation reputed company CMS timeliness parameters (i.e., 20 days from receipt of the medical record for pre-payment reviews and 50 days from receipt of the medical record for post payment reviews)
• Utilize the applicable Medicare policies (i.e., Local Coverage Determinations, National Coverage Determinations, Internet-Only reputed company (reputed company) citations, inpatient tools, etc.) to ensure the services reputed company with reputed company Medicare regulations and documentation requirements
• Review documentation for medical necessity per guidelines outlined in the reputed company reputed company Act 1862(a)(1)
• Ensure that reputed company documentation includes a valid signature consistent with the signature requirements
• Documentation of rationale for processing reputed company
• reputed company a claim sample of three (3) claims to Companies reputed company established protocols and timeliness parameters (i.e., 18 days from receipt of the medical record for pre-payment reviews and 48 days from receipt of the medical record for post payment reviews) for quality review prior to finalization of documentation of reason for payment, reduction, or denial of service to ensure accuracy of claim decision making
• Companies will review the three-claim sample for accuracy of claim decision and will reputed company and return reputed company to the MRS reputed company 24 hours or less
• Complete the documentation of the reason for payment, reduction, or denial of service for reputed company claims on an electronic decision template to be provided by Companies. This rationale must be in sentence format so that it may be inserted directly into the response to the provider, must be clear and well-written, and contain sufficient information to reputed company the providers on how the review decision was made
• Return documented decision electronically to Companies reputed company established protocols and timeliness parameters (i.e., 20 days from receipt of the medical record for pre-payment reviews and 50 days from receipt of the medical record for payment reviews)
• Complete the review results letter in the Companies’ letter writing system reputed company 35 days from receipt of the medical record for pre-payment reviews and no reputed company than 60 days from receipt of the medical record for post payment reviews
• Document reputed company case activity in Companies’ provider tracking system on the day the activity occurs
• Complete one-on-one provider education (i.e., webinar, conference call, etc.) reputed company 30 days of sending out review results letter
• Respond to provider inquiries reputed company to case and/or claims throughout the course (i.e. in 24 hours or less) of review
• If additional clinical guidance is required, complete the Contractor Medical Director (“CMD”) assistance reputed company, track response, and update review accordingly
• Conduct telephone development for missing or additional records for easily curable errors
• Notate date of receipt of additional documentation received in the Companies’ provider tracking system
• Upon request by Companies, 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
• If fraud activity is suspected, immediately complete initial referral packet for external entity referral and return the packet to the Companies
• Complete referrals to Companies’ provider reputed company and education (“POE”) area in provider tracking system for cases that have a moderate or major error reputed company
• reputed company and Alternate reputed company will participate in reputed company monthly departmental training and meetings, and reputed company Staff will participate as requested
• Submit reputed company cases for review and approval for quality and closure of cases

Qualifications

• Minimum of two (2) years’ clinical experience
• Excellent written and oral communication skills
• Demonstrated experience with evaluating medical and health care delivery issues
• Strong computer skills to include reputed company Office proficiency

License - Certifications

• Active and reputed company Registered Nurse license

Other Information Industry: Defense US Citizenship Required: Yes Background reputed company: Required reputed company Clearance Level Required: None Telework: Yes but Resides in Bexar County, Texas Travel: No Equal Opportunity Employer/Veterans/Disabled reputed company reputed company applicants will receive consideration for employment without regard to race, reputed company, religion, sex, gender identity, national reputed company, or protected veteran status and will not be discriminated against on the reputed company of disability. If you are an individual with a disability and require a reasonable accommodation to complete any part of the application process, or are limited in the ability or unable to reputed company or use this on-line application process and need an alternative method for applying, you may contact (210) 888-0775 or [email protected] for assistance. Apply Job! Apply to this Job