RELI GROUP INC

Role Description Perform automated and complex medical record and claim reviews to make coverage determinations based on applicable Medicare coverage policies and payment rules, coding guidelines, National and Local Coverage Determinations, utilization/practice guidelines, and clinical review judgment. Provides professional assessment, planning, coordination, implementation, and reporting of complex data to support the Recovery Auditor Validation Contract (RVC). Essential Functions - Perform accuracy review of automated and complex Medicare medical record and claims review in accordance with all State and Federal mandated regulations/guidelines. - Perform accuracy reviews as a Special Study requested by CMS. - Document findings for each claim in a clear and concise manner. - Compile a report explaining the claim reviews, including identified patterns, inappropriate determinations, as well as recommendations. - Reasonably determines appropriateness to consult a Subject Matter Expert (SME) for clarification. - Perform medical record reviews in response to RAC disputes/disagrees with the RVC review decisions. - Perform accuracy review of the New Issue Proposal for appropriate regulations, references, policies, and edit parameters. Compile a report of analysis and recommendations to submit to CMS. - Perform New Issue Quality Assurance Review for accuracy of all criteria and references. - Consistently meet or exceed productivity and accuracy standards of 95% minimum IRR established by the customer and/or the Company. - Report problems to the Medical Review Manager (MRM) and Project Manager (PM) regarding unique record or process issues. - Maintain security and confidentiality of medical records and Protected Health Information (PHI) and Personally Identifiable Information (PII). - Consistently meet attendance standards established by the Company and follows the telecommuting policy. - Interact appropriately with peers, co-workers, other Contractors, and the customer, when necessary. Contribute to building a positive team spirit. - On occasions may be asked by the MRM or PM to assist with development of training and/or resource materials. - May be asked to assist with precepting of new Medical Review Nurses (MRNs). - Perform other duties and projects as assigned. Qualifications - Registered Nurse, with a current unobstructed license to practice nursing in the United States. Graduate of a Board approved Registered Nursing program. - A Bachelor’s Degree in Nursing (BSN) or other related field is preferred. - Certification in coding highly preferred. - A minimum of three (3) years clinical experience in an acute care hospital, skilled nursing facility, and/or an office/clinic-based medical practice. - A minimum of three (3) or more years’ experience in medical/utilization medical record review particularly with Medicare and/or Medicaid. - Proficiency in research, interpretation, and application of Medicare, Medicaid, and local healthcare regulations and policies. - Must be proficient in Microsoft Office Suite such as Outlook, Excel and Word. Skills & Abilities - Ability to work independently and maintain an elevated level of concentration. - Capable of consistency, speed, and accuracy of task. - Ability to read, analyze, and interpret physician documentation. - One year or more of utilizing InterQual and/or Milliman guidelines against inpatient services experience is preferred. - Ability to communicate clearly and professionally with all levels of the organization, both written and verbal. - Ability to work well in a remote team environment, to collaborate with others, and interface with team members internal and external to the organization. - Establishes and maintains effective professional relationships with internal and external stakeholders. - Must be able to adapt to organizational change. - Must be proficient in Microsoft Office Suite such as Outlook, Excel, and Word. - Flexibility and ability to plan, prioritize, and execute multiple tasks in a fast-paced environment. - Self-motivated, well-organized, and detail oriented. - Ability to maintain a high level of confidentiality and integrity. Benefits - The annual salary range for this position is $80,000 to $95,000. - Actual compensation will depend on a range of factors, including but not limited to the individual’s skills, experience, qualifications, certifications, location, other business and organizational needs, and applicable employment laws. - RELI Group provides a variety of additional benefits to its employees.