Responsibilities:
• Performs comprehensive pre-existing reviews and makes clinical determinations of pre-existing or not pre-existing status based on medical judgment and contractual eligibility of the services provided. The comprehensive review includes review of related claims and customer service documentation, and review and interpretation of all medical records. Performs these reviews in a timely manner meeting departmental and corporate turnaround requirements. • Performs thorough research and provides complete documentation for rationale to support both determinations of pre-existing and not pre-existing, as well as specific written instructions regarding additional information necessary to complete the review.
• In addition to initial pre-existing reviews, performs review of rider-related diagnoses, potential misrepresentation referrals, provider and member appeals, and rider-related drug appeals.
• Seeks the advice of the Utilization Management Medical Director as appropriate.
• Proficient in interpreting benefits, contract language specifically symptom-driven, treatment-driven, look-back periods, and rider information, and medical policy language.
• Knowledgeable of all types of pre-existing reviews and have the flexibility to perform each type of review (group, PHC and TRH).
• Utilizes the following system applications when performing reviews: FACETS, FileNet, Outlook, and Intranet, Internet Explorer to research and cross-reference diagnoses and treatment, Microsoft Office, Encoder Pro, Adobe Reader, Adobe Writer, and TRH Imaging software to review applications for potential misrepresentation referrals.
• Navigates in FileNet using all methods for locating and retrieving medical records associated with the specific claim to be reviewed as well as related claims.
• Maintains and/or assists with tracking reporting, and audits to monitor productivity, turnaround times, and quality. • Interacts with Claims, Customer Service, Compliance, Configuration, and other departments as necessary to ensure all guidelines are followed.
• Performs or participates in special studies or projects as directed by department management.
• Promotes positive public relations with providers, member, employees, and the community at large.
• Assists or performs other duties as assigned.
Education
• Minimum of at least 5 years of clinical experience, must have active registered nurse license in the state of Tennessee or hold a license in the state of their residence if the state is participating in the Nurse Licensure Compact Law.
• BSN preferred.
Experience
• Must be PC literate and experience in Windows and Microsoft Office is preferred. Skills/Certifications
• Must possess excellent verbal and written communication skills with problem solving abilities, organizational, leadership, and interpersonal skills.
• Ability to work independently and handle multiple tasks.
Riya Khem
Life Science Recruiter
Integrated Resources, Inc.
IT Life Sciences Allied Healthcare CRO
Certified MBE |GSA - Schedule 66 I GSA - Schedule 621I
DIRECT # - 732 -844-8721 | (W) # 732-549-2030 - Ext - 311 |(F) 732-549-5549
Job details are sourced from the employer's original posting.
Open job postingAbout the company
Integrated Resources, Inc is a premier staffing firm recognized as one of the tri-states most well-respected professional specialty firms. IRI has built its reputation on excellent service and integrity since its inception in 1996. Our mission centers on delivering only the best quality talent, the first time and every time. We provide quality resources in four specialty areas: Information Technology (IT), Clinical Research, Rehabilitation Therapy and Nursing.