Medical Review Nurse

Heart to Heart Hospice•Plano, TX

About The Position

You can Make A Difference in the lives of others! At Heart to Heart Hospice, we provide “Compassionate Care from Our Hearts to Yours.” Our employees enhance the lives of patients with life-limiting illnesses and their loved ones,during a time when compassionate care is needed most. We are dedicated to making a difference in the lives of employees, offering the opportunity to be associated with caring teammates, and creating positive contributions in each community we serve. Medical Review Nurse

Requirements

Licensed Vocational or Registered Nurse required (active state license)
Minimum of two (2) years of experience in Hospice nursing and preferably Quality/QAPI experience and two (2) years med-surg experience prior to hospice
Minimum of one (1) year of experience responding to ADRs and appellate process in hospice
Working knowledge of Local Coverage Determinants for Hospice (multiple states)
Working understanding of Medicare rules and regulations related to hospice
Excellent computer skills (Microsoft office and Imaging Software), ideally has experience with Home Care Home Base, Kinnser, and Waystar.
Ability to travel
Current Driver's License, reliable transportation, and provide ongoing valid and current auto liability insurance

Responsibilities

Monitor Waystar for new assignments. Work in order by due date - next due first.
Organize the information in the document imaging software as requested by the auditor for the additional development request and the appellate process required for packet (chart) submission.
Complete Technical Review of created packet by using excel based Audit tool. – Name audit tool using naming convention and save in “Audit tool” folder.
Perform a Clinical Review a medical record identifying qualifying information supporting hospice eligibility, patient decline and less than six month terminal prognosis based on the local coverage determinations.
Assist in Administrative Law Judge Hearing preparation as needed. Create a chronology of events (Evidence Worksheets) for use in hearing.
Productivity expectation - 1-2 ADR request per day (letter and Packet) – This expectation is for a 30-31 day claim period. Multiple benefit periods/claim ADRs – may take additional time.
Timely submission of all documentation
Performance of other duties as required
Ensure overall compliance with local, state and federal laws, Medicare regulations, and established personnel policies and procedures