Independent Dispute Resolution Entity Nurse (Remote)

ProPeer•Schertz, TX

1d•Remote

About The Position

The Independent Dispute Resolution Entity (IDRE) Nurse role supports the Independent Review Organization (IRO) in quality assurance efforts of commercial health non-appeal, internal appeal, state external appeal, and Federal PPACA appeal cases. All IDRE Nurses are responsible for conducting quality assurance checks including analyzing medical records, and prior denials, ensuring proper clinical specialty is utilized for reviews, and appropriate evidence-based literature is used in support of rationale. Additionally, the IDRE Nurses ensure that details of the patient’s condition, physician orders, course of treatment, and well-supported rationale are present within the clinical reviewer’s final review. This job requires access to confidential and sensitive information, requiring ongoing discretion and secure information management.

Requirements

Knowledge of Basic Anatomy
Comprehension of medical/surgical modalities and imaging techniques
Ability to analyze clinical documentation in relation to utilization reviews
Ability to Interpret and apply appropriate guidelines to utilization reviews
Ability to use logic and reasoning to determine and utilize appropriate evidence-based guidelines
Ability to read, analyze, and interpret documents, reports, technical procedures, governmental regulations, and correspondence
Ability to write routine reports and correspondence; and ability to present information in one-on-one, small group, and large group situations to management and staff
Ability to apply proper grammar, spelling, punctuation, and formatting to typed material
General Typing Skills at 45wpm
Ability to use Microsoft products, Word, Excel, PowerPoint, Outlook
Perform various computer functions including saving, copying, pasting, scrolling, etc
High level of oral and written communication skills with a demonstrated ability to deliver excellent customer service
Communicate professionally and effectively with physician reviewers, staff, and clients from all departments within and outside the Company.
Demonstrated ability to work cross-functionally to solve complex problems and improve quality and service
Must have a track record of producing work that is highly accurate, demonstrating attention to detail
Build professional relationships that support the brand and its image
Ability to multi-task and quickly adapt to a fast-paced environment
Maintain a positive attitude and outstanding customer service while working closely internally with Nexus team members, panel physicians, and clients
Strong organizational skills
Attention to detail
Proficiency in English with an aptitude for spelling and grammar
Exemplary planning and time management skills
Ability to multi-task, prioritize, and work in high pressure, deadline-driven environment
Demonstrated ability to problem solve complex, multifaceted, situations
Ability to engage easily in abstract thought
Strong organizational and task prioritization skills
RN with 1- 3 years of experience in a Managed Care setting
Proficient computer skills: able to navigate through multiple software systems including, but not limited to, Microsoft Word, Excel, and Outlook

Responsibilities

Comprehension of medical/surgical modalities and imaging techniques
Ability to analyze clinical documentation, prior denials, and supporting documentation to ensure the quality of the clinical reviewer’s final review
Audit and analyze patient records to ensure quality patient care and appropriateness of services
Utilize pre-approved criteria/guidelines and plan language to validate medical necessity/appropriateness of treatment (e.g. Policy Plan Language, Milliman Care Guidelines, InterQual)
Ability to understand and analyze plan language documentation
Proper citation of evidence-based literature and requirements of clients
Keeps current with regulation changes
Perform a low to moderate amount of research on a case-by-case basis
Conducts audits to ensure high-quality, professional reports that are free of grammar and spelling errors are delivered to the client
Communicate with physician reviewers to address/correct errors or omissions and to investigate questionable claims
Responsible for amending reports, as needed, with any additional clinical information provided
Participates in an interdisciplinary health care team to achieve positive outcomes
Ability to complete an average daily caseload of 15-20 cases once released from training
Requires regular and consistent attendance
Other duties as assigned