[Hiring] RN, Clinical Record Review @Managed Medical Review Organization

Role Description

We are searching for a new RN to join our team. Our Nurses enjoy the flexibility to work remotely and do not have face-to-face Patient contact. This position is performed in a home-office environment and requires great telephonic/customer service and documentation skills in addition to clinical experience.

• Upon receipt of a case, verify the presence of any real or perceived conflict of interest, consistent with corporate policy (Ref: Policy and Procedure- Conflict of Interest).
• As applicable, based on the HCR service type requested, verify the appropriate service, Physician Reviewer Specialty, and review questions upon review of the case and the associated medical records.
• Maintain communication with the Physician Reviewer (as applicable) during the review process to ensure timely and accurate delivery of the review service being completed.
• Verifies current credentials for the Physician Reviewer. Verify that credentialing has not expired and is complete consistent with corporate policy (Ref: MMRO Credentialing Policy & Procedure).
• Maintain communication, including but not limited to any delays in service, with the referring party as required for the case type being performed.
• As applicable, discuss and review training material with Physician Reviewers.
• Maintain policy and process requirements for State Mandated External Reviews, including the submission of all required correspondence and documentation consistent with state requirements.
• Accurately and consistently document all required case activities in W5.
• Accurately inputs Physician Reviewer cost and client charge into W5 for invoicing/payment by the Bookkeeper.
• Quality review rough draft versions of HCR reports to ensure clinical quality and compliance, including but not limited to: clinical quality issues (i.e. clinical substantiation, clinical inconsistences, plan language compliance) incomplete reports, report inconsistencies, and grammar or typographical errors.
• Communicate, verbally or in writing, with the Physician Reviewer, to remediate any quality issues identified, consistent with corporate policy.
• Assist the Physician Reviewer, as applicable, in selecting and utilizing evidence-based criteria and support of clinical rationale.
• Perform final review of HCR reports in preparation of submitting to client.
• As applicable, participate in Physician Reviewer orientation/training programs, including the development of customized or individualized physician orientation and training programs.
• As applicable, participate in the Quality Improvement Committee and/or participate in Quality Improvement Projects, as requested by the Quality Department.
• Address ongoing quality issues with the Quality Department and suggest quality improvement initiatives, as deemed appropriate.
• Seeks the advice of the Executive Medical Director, as needed, when performing assigned duties.

Qualifications

• Must reside in: Michigan, Florida, Idaho, Texas, Minnesota or Illinois.

Company Description