[Hiring] Registered Nurse - Medical Review Specialist @Avosys Technology, Inc.

Role Description

Is it your calling to serve our Nation's Heroes? Avosys is seeking a Registered Nurse - Medical Review Specialist to provide services to the military and their families.

Qualifications

• Minimum of two (2) years' clinical experience
• Active and current Registered Nurse license
• Bachelor's required
• Excellent written and oral communication skills
• Demonstrated experience with evaluating medical and health care delivery issues
• Strong computer skills to include Microsoft Office proficiency
• Preferred (but not required) qualifications:
• Insurance industry experience
• Oral and written English-Spanish bilingual skills

Requirements

• Perform clinical reviews of Medicare Part A and Part B claims for Medical Review, Redeterminations/Appeals (Appeals), and Prior Authorization requests.
• Review medical record documentation within CMS timeliness parameters.
• Utilize applicable Medicare policies to ensure compliance with regulations and documentation requirements.
• Review documentation for medical necessity per guidelines outlined in the Social Security Act 1862(a)(1).
• Ensure that all documentation includes a valid signature consistent with the signature requirements.
• Provide a claim sample of three (3) claims for quality review prior to finalization of documentation.
• Complete documentation of the reason for payment, reduction, or denial of service on an electronic decision template.
• Return documented decision electronically to Companies via established protocols.
• Complete the review results letter within specified timeframes.
• Document all case activity in Companies' provider tracking system.
• Complete one-on-one provider education within 30 days of sending out review results letter.
• Respond to provider inquiries related to case and/or claims.
• Complete the Contractor Medical Director ("CMD") assistance form if additional clinical guidance is required.
• Conduct telephone development for missing or additional records.
• Initiate or participate in provider teaching activities upon request.
• Complete initial referral packet for suspected fraud activity.
• Complete referrals to Companies' provider outreach and education area for cases with moderate or major error rate.
• Participate in all monthly departmental training and meetings.
• Submit all cases for review and approval for quality and closure of cases.

Benefits

• Maximize family time with no weekend, Holiday, or on-call requirements.
• Maintain work-life balance with guaranteed 8-hour shifts.
• Achieve peace of mind with malpractice insurance provided at no cost.

Company Description

Avosys is a growing integrator of professional, technological and management solutions services. Founded in 1998, Avosys provides services nationwide to Federal, Commercial, Local and State clients.