[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

Responsibilities

• Perform clinical reviews of Medicare Part A and Part B claims for Medical Review, Redeterminations/Appeals, and Prior Authorization requests.
• Review medical record documentation within CMS timeliness parameters:
• 20 days from receipt of the medical record for pre-payment reviews
• 50 days from receipt of the medical record for post payment reviews
• 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.
• Document rationale for processing decisions:
• 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 for all claims 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 on the day the activity occurs.
• 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 throughout the review process.
• Complete the Contractor Medical Director assistance form if additional clinical guidance is required.
• Conduct telephone development for missing or additional records for easily curable errors.
• Initiate or participate in provider teaching activities upon request.
• If fraud activity is suspected, complete initial referral packet for external entity referral.
• Complete referrals to Companies' provider outreach and education area for cases with moderate or major error rates.
• Participate in all monthly departmental training and meetings.
• Submit all cases for review and approval for quality and closure of cases.
• Job responsibilities are subject to change to meet Military Treatment Facility requirements.

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. We recognize the foundation of our firm is our people and we continue to rise above our competition by hiring the best.