Registered Nurse Senior Medical Reviewer (Home Health and Hospice) - CGS

CGS Administrators, LLC-posted 2 months ago
Full-time • Mid Level
Tennessee, IL
501-1,000 employees
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Acts as Team Lead for specialty programs, medical review, utilization management, and case management areas by providing assistance and support to unit supervisor/manager by giving direction/guidance/training to staff. Ensures appropriate levels of healthcare services are provided.

  • Functions as team leader/senior-level Medical Reviewer.
  • Provides leadership/guidance/direction/training to staff.
  • Maintains working knowledge of unit functions and ability to interpret to new hires, department innerworkings and workflow.
  • Acts as resource for staff/external entities troubleshooting as well as resolving issues.
  • Keeps manager informed of any problems/issues that need resolving.
  • Assists management with monitoring workflow and workloads.
  • Participates in departmental quality reviews.
  • Follows process to ensure quality plan is adhered to and communicated to all parties.
  • Gives/receives feedback regarding medical review decision making and technical claims processing issues.
  • Ensures that quality work instructions/forms/documents are developed/revised as needed.
  • Provides quality service and communicates effectively with external/internal customers in response to inquiries.
  • Obtains information from internal departments, providers, government, and/or private agencies to resolve discrepancies/problems.
  • Participates in compliance initiatives and other-directed activities.
  • Participates/oversees special projects as requested by management.
  • Active, unrestricted RN licensure from the United States and in the state of hire, OR active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), OR active, unrestricted licensure/certification from the United States and in the state of hire in specialty area as required by hiring division/area.
  • Associate Degree - Nursing, OR Graduate of Accredited School of Nursing.
  • Four years clinical experience, OR two years clinical and two years medical review/utilization review, OR a combination of health plan, clinical, and business experience totaling four years.
  • Working knowledge of managed care and various forms of healthcare delivery systems.
  • Strong clinical experience to include home health, rehabilitation, and/or broad medical surgical experience.
  • Knowledge of specific criteria/protocol sets and the use of the same.
  • Working knowledge of word processing and spreadsheet software.
  • Ability to work independently, prioritize effectively, and make sound decisions.
  • Good judgment skills.
  • Demonstrated customer service, organizational, and presentation skills.
  • Demonstrated proficiency in spelling, punctuation, and grammar skills.
  • Demonstrated oral and written communication skills.
  • Ability to persuade, negotiate, or influence others.
  • Analytical or critical thinking skills.
  • Ability to handle confidential or sensitive information with discretion.
  • Ability to lead/direct/motivate others.
  • Prior experience in Home Health & Hospice (HHH) Medical Review, Appeals, Utilization Review or Quality Assurance strongly preferred.
  • Five years of varied clinical RN experience in critical care, emergency, inpatient medical/surgical, and/or Durable Medical Equipment (DME).
  • Proficient in Excel.
  • Team player.
  • Self-starter.
  • Subsidized health plans, dental and vision coverage.
  • 401k retirement savings plan with company match.
  • Life Insurance.
  • Paid Time Off (PTO).
  • On-site cafeterias and fitness centers in major locations.
  • Education Assistance.
  • Service Recognition.
  • National discounts to movies, theaters, zoos, theme parks and more.
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