Career Opportunities at Provider Resources, Inc. (PRI)
Position Description: Medical Review Manager (MRM)
Reporting to the Provider Resources, Inc (PRI) Medical and Assistant Medical Directors, the Medical Review Manager (MRM) will play a critical role in managing the professional nurse reviewer staff of PRI. As a member of the management team, the MRM will be an advisor, integral in the evaluation and implementation of effective and efficient nurse review services for all PRI clients. S/he will be responsible for overseeing all aspects of the nurse review function and for maintaining maximum quality throughout all nurse review activities.
Responsibilities
- Understand and represent PRI’s mission, vision, and values to all internal and external customers
- Engage clients in appropriate communication that manages client expectations and builds a collaborative relationship with the client
- Interact with government and private sector clients, partners, and PRI staff in a professional and accountable manner, and as a representative of PRI management
- Contribute to business development efforts for new sales and marketing to promote the business, including responses to requests for quotes, sources sought, proposals, and/or presentations as requested
- Manage staff level positions by administering all HR functions, including but not limited to hiring, terminating, conducting performance reviews, setting performance standards, approving work schedules, assigning and directing workload, training and developing staff, coaching, etc. to ensure goals are met
- Plan, design and recommend business processes to improve and support business activities
- Analyze and document client’s business requirements and processes and communicates these by constructing conceptual data and process models, including data dictionaries and volume estimates from organization
- Facilitate meetings with clients to gather and document requirements and explore potential solutions
- Assist in providing time estimates for project related tasks
- Develop, approve implement and ensure department compliance with Medical Review policies and procedures
- Assess results of medical record reviews conducted by Medical review nurses and ensure the standards defined by the Statement of Work (SOW), the Program Integrity Manual (PIM), CMS directives and any other regulations or client directives related to Medical Review are in adherence
- Write clear, concise reports, proposals and business correspondence
- Perform all duties of a Senior Medical Review Nurse
- Create test scenarios and develops test plans to be used in testing the business applications in order to verify that client requirements are incorporated into the system design
- Provide input into developing and modifying systems to meet client needs and develops business specifications to support these modifications
- Assist in coordinating business analyst tasks on information technology projects and provides support to other team members
- Assist in analyzing testing results in all phases
- Participates in technical reviews and inspections to verify ‘intent of change’ is carried out through the entire project
- Ensure that the Medical Review Department is in compliance with the established Quality Management System and ISO requirements Understand and represent PRI’s mission, vision, and values to all internal and external customers
- Perform other duties as requested
Requirements:
- Bachelor’s Degree in Nursing (BSN), business, information systems or other related field preferred
- Must be a Registered Nurse (RN) with an active license in state of residence
- Ten or more years experience in medical/utilization review
- Knowledgeable of ICD-9-CM, CPT-4 and HCPCS coding
- Five or more years business analysis experience
- Experience working with the interface of information technology with functional groups within an organization
- Experience working with software application concepts and system implementation
- Proficient in use of Microsoft office suite such as Outlook, Access, Excel, PowerPoint and Word
- Knowledge of Interqual and Milliman guidelines
- Certification in coding, utilization management/review and/or the quality improvement process preferred
- Excellent verbal and written communication skills
- Must have no adverse actions pending or taken against him/her by any State or Federal licensing board or program
- Must have no conflict of interest (COI) as defined in 1154(b)(1) of the Social Security Act (SSA)
- Ability to obtain and maintaiU.S. Government Security Clearance
Resume, cover letter, and salary requirements can be sent to HR@Provider-Resources.com