[Hiring] Nurse Reviewer @Commence

Role Description

The Nurse Reviewer position is responsible for supporting and conducting reviews and determinations for independent dispute resolutions at both the Federal and State levels. This role involves:

• Analyzing medical records
• Ensuring proper documentation
• Providing quality assurance checks to support the final determination
• Resolving claim disputes submitted by various parties, such as physicians, hospitals, institutions, pharmacies, and other licensed healthcare providers
• Resolving disputes submitted to the Federal Independent Review (IDR) process
• Conducting impartial reviews of healthcare services to resolve disputes between healthcare providers, facilities, and payers
• Providing objective assessments of billing, coding, and other issues related to disputed claims

The role requires conducting all job duties efficiently, promptly, productively, consistently, and courteously while maintaining a high level of professionalism.

Qualifications

• Maintain an active license in nursing (at a minimum, RN required)
• Five years of full-time equivalent experience providing direct care to patients
• Hold a non-restricted nursing license in any state in the US

Requirements

• Conduct an initial assessment of documentation from both the initiating and responding parties
• Review submitted documentation to identify missing documents and determine what is required to resolve the dispute
• Follow procedures to obtain the appropriate documentation
• Determine the appropriate type of clinical reviewer necessary to complete the case, such as a medical coder or a physician
• Prepare documents for the arbitrator reviewer assigned and provide instructions as needed
• Collaborate with the legal team to facilitate resolution of disputes
• Draft professional determination correspondence
• Perform quality assurance checks on determinations according to Federal or State guidance
• Audit and analyze patient records to ensure appropriate determination
• Stay current with regulation changes and perform research on a case-by-case basis
• Deliver high-quality, professional determinations free of grammar and spelling errors
• Amend reports with additional clinical information when necessary
• Participate in an interdisciplinary health care team to achieve positive outcomes

Preferred Qualifications

• Ability to analyze clinical documentation and apply appropriate guidelines
• Strong oral and written communication skills with excellent customer service
• Ability to multitask and adapt to a fast-paced environment
• Strong organizational skills and attention to detail
• Knowledge of claim review processes including billing, Current Procedural Terminology (CPT) coding, and Explanation of Benefits
• Familiarization with navigating electronic documents like PDFs, Microsoft Excel, Microsoft Word, and experience using Microsoft Outlook
• Familiarization with electronic data repositories such as SharePoint and/or ShareFile
• Exceptional skills in managing sensitive and confidential information
• Strong organizational abilities, written, and verbal communication skills in English
• Ability to work both independently and collaboratively with other team members to include clinical reviewers, physicians, and attorneys
• Skilled in prioritizing tasks to align with business needs and assignments
• Appeal and/or claim dispute-related experience
• Medical Coding Certification preferred
• Experience with Utilization Review preferred

Organizational "Fit" Considerations

• Schedules may vary and may include weekend and holiday shifts
• This position requires established, professional relationships with internal personnel at all levels within the company and with beneficiaries, representatives, providers, and other stakeholders

Work Environment/Physical Demands

The work environment and physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• This is an office/remote position
• While performing the duties of this job, the employee regularly works in a climate-controlled environment
• Candidates must be able to sit, read, work on a computer, and watch a computer screen for extended periods of time
• Occasionally required to stand, walk, use hands and fingers, kneel or crouch