Professional Review Nurse

CorVel • Vernon, WI

14d • 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 position.

Requirements

• 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
• 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

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

Benefits

• Medical (HDHP) w/Pharmacy, Dental, Vision, Long Term Disability, Health Savings Account, Flexible Spending Account Options, Life Insurance, Accident Insurance, Critical Illness Insurance, Pre-paid Legal Insurance, Parking and Transit FSA accounts, 401K, ROTH 401K, and paid time off

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree