Professional Review Nurse

CorVel•Syracuse, NY

66d•Remote

About The Position

The Professional Review Nurse provides analysis of medical services to determine appropriateness of charges on multiple types of medical bills and review of medical reports to determine appropriateness of medical care. This is a remote role. ESSENTIAL FUNCTIONS & RESPONSIBILITIES: Identify the necessity of the review process and communicate any specific issues of concern to the claims examiner/client and/or direct reporting manager Collect supporting data and analyze information to make decisions regarding appropriateness of billing, delivery of care and treatment plans Utilize clinical and/or technical expertise to address the provision of medical care and identify inappropriate billing practices and errors, such as: duplicate billing, unbundling of charges, services not rendered, mathematical and data entry errors, undocumented services, reusable instrumentation, unused services and supplies, unrelated and/or separated charges, quantity and time increment discrepancies, inconsistencies with diagnosis, treatment frequency and duration of care, DRG validation, service/treatment vs. scope of discipline, use of appropriate billing protocols, etc. Document work and final conclusions in designated computer program Additional duties as assigned

Requirements

Concise and effective verbal and written communication skills
Ability to interface with claims adjusters, attorneys, physicians and their representatives, advisors/clients, and co-workers
Ability to effectively promote all Professional Review products with attorneys, claims examiners, customers and management
Strong ability to effectively negotiate provider fees
Must be proficient with Microsoft Office applications
Knowledge of worker's compensation claims preferred
Must maintain current licensure as a Registered Nurse in the state of employment with a minimum of 4 years clinical experience
A minimum of an Associate Degree in Nursing as well as have a thorough knowledge of both C.P.T. and I.C.D.9 codes preferred

Nice To Haves

Medical bill auditing experience preferred
Experience in the clinical areas of O.R., I.C.U., C.C.U., E.R., and orthopedics preferred
Prospective, concurrent and retrospective utilization review experience preferred

Responsibilities

Identify the necessity of the review process and communicate any specific issues of concern to the claims examiner/client and/or direct reporting manager
Collect supporting data and analyze information to make decisions regarding appropriateness of billing, delivery of care and treatment plans
Utilize clinical and/or technical expertise to address the provision of medical care and identify inappropriate billing practices and errors, such as: duplicate billing, unbundling of charges, services not rendered, mathematical and data entry errors, undocumented services, reusable instrumentation, unused services and supplies, unrelated and/or separated charges, quantity and time increment discrepancies, inconsistencies with diagnosis, treatment frequency and duration of care, DRG validation, service/treatment vs. scope of discipline, use of appropriate billing protocols, etc.
Document work and final conclusions in designated computer program
Additional duties as assigned