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Overall Purpose of the Position:
Performs medical reviews using clinical/medical information provided by physicians/providers and established criteria/protocol sets or clinical guidelines. Documents decisions using indicated protocol sets or clinical guidelines. Provides support and review of medical claims and utilization practices. The positions are for a sub-contract with Palmetto GBA.
Performs medical reviews using clinical/medical information provided by physicians/providers and established criteria/protocol sets or clinical guidelines. Documents decisions using indicated protocol sets or clinical guidelines. Provides support and review of medical claims and utilization practices. The positions are for a sub-contract with Palmetto GBA.
Worksite:
This is a Work-from-home position, following a minimum of six-week training (onsite and virtually) at our corporate office that we share with Palmetto GBA located at 2743 Perimeter Parkway, Augusta, GA 30909. We are classified as a HUBZone small business which means that we ensure a percentage of our workforce lives in a HUBZone (Historically Underutilized Business Zone) while working for Broadway Ventures. We will give a strong preference to applicants who live in a HUBZone year round. To verify whether you live in a HUBZone, you may view the following link: HUBZone Map (sba.gov)
Responsibilities of Job:
70% Performs medical claim reviews for one or more of the following: claims for medically complex services, services that require preauthorization/predetermination, requests for appeal or reconsideration, referrals for potential fraud and/or abuse, correct coding for claims/operations, Make reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines. Determines medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement. Monitors process’s timeliness in accordance with contractor standards. Documents medical rationale to justify payment or denial of services and/or supplies.
20% Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.
10% Participates in quality control activities in support of the corporate and team-based objectives.
Provides guidance, direction, and input as needed to LPN team members. Provides education to non-medical staff through discussions, team meetings, classroom participation, and feedback. Assists with special projects and specialty duties/responsibilities as assigned by management.
Values: Consistently demonstrates high standards of integrity by supporting the Company’s mission and values and adhering to the Corporate Code of Conduct.
Confidentiality: Maintains high regard for member, customer and/or beneficiary privacy in accordance with the corporate confidentiality, privacy and security policies and procedures.
Performs other duties as assigned
Minimal Job Requirements:
Education: Associate Degree – Nursing or Graduate of an accredited School of Nursing.
Work Experience: 2 years clinical experience.
Skills and Abilities:
Ability to work independently, prioritize effectively, and make sound decisions.
Good judgment skills.
Demonstrated customer service and organizational skills.
Demonstrated oral and written communication skills.
Analytical or critical thinking skills.
Ability to handle confidential or sensitive information with discretion.
Software and Other Tools: Microsoft Office.
Licenses and Certificates: Active RN licensure instate hired OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC).
Preferred Requirements:
Education: Bachelor’s degree – Nursing, OR, Graduate of an Accredited School of Nursing. Equivalency:
Skills and Abilities:
Knowledge of spreadsheet and database software.
Ability to persuade, negotiate, or influence others.
Working knowledge of managed care and various current forms of healthcare delivery systems; strong clinical experience home health, rehabilitation, and/or broad medical surgical experience.
Knowledge of Medicare and/or regulations/policies/instructions/provisions, home health, system/processing procedures for medical review.
Knowledge of or ability to learn specific criteria/protocol sets and the use of the same.
Software and Other Tools: Working knowledge of Microsoft Excel, Access, or other spreadsheet/database software.
We will be performing a background check and drug test prior to the start of employment.
Job Type: Full-time
PI199214748
