Career Opportunities at Provider Resources, Inc. (PRI)
Position Description: Medical Review Nurse (MRN)
Reporting to the Medical Review Manager (MRM), the Medical Review (MRM) will provide professional assessment, planning, coordination, implementation and reporting of complex clinical data and support the medical review operations of Provider Resources, Inc (PRI). The MRN position will perform comprehensive medical record and claim reviews to make payment determinations based on applicable coverage policies, coding guide lines and utilization and practice guidelines.
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
- 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
- Perform medical record and claims review in accordance with all State and Federal mandated regulations.
- Maintain compliance with all regulation changes as they impact medical and utilization review practices.
- Analyze patient records and participate in interdisciplinary collaboration with PRI staff and all recognized teaming partners and/or subcontractors.
- Document all review information into the appropriate Medical Review form, report and/or system. Communicate these report results to the appropriate supervisor.
- Utilize electronic health information imaging
- Utilize Internet and Intranet resources for policy verification
- Utilize Mainframe shared system access to the Centers for Medicare & Medicaid Services’ (CMS), Common Working File (CWF) to verify claims data information by query and search activities
- Make clinical judgments based on clinical experience when applicable
- 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) or other related field preferred
- Will give consideration to equivalent combination of education and experience in lieu of a degree
- Must be a Registered Nurse (RN) with an active license in state of residence
- Will give consideration to a Licensed Practical Nurse (LPN) with an active license in state of residence with equivalent and applicable experience in lieu of a RN.
- Two or more years experience in medical/utilization review
- Knowledgeable of ICD-9-CM, CPT-4 and HCPCS coding
- Knowledge of Microsoft office suite such as Outlook, Access, Excel and Word
- Certification in coding, utilization management/review and/or the quality improvement process preferred
- One or more years of DRG validation review is preferred
- One year or more of utilizing InterQual and/or Milliman guidelines against inpatient services experience is preferred
- One year or more of federal and local policy applications in relation to insurance procedures for medical necessity and benefit coverage preferred
- 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 maintain U.S. Government Security Clearance
Resume, cover letter, and salary requirements can be sent to HR@Provider-Resources.com