Clinical Review Nurse - Novitas

SUMMARY STATEMENT
The Clinical Review Nurse is responsible for reviewing and making medical determinations as to the validity of health claims and levels of payment in meeting national and local policies as well as accepted medical standards of care. The incumbent applies clinical knowledge to assess the medical necessity, level of services and appropriateness of care which may include cases requiring prior authorization, complex pre-payment medical review or post-payment medical review.

 

 

ESSENTIAL RESPONSIBILITIES
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This list of essential job functions is not exhaustive and may be supplemented as necessary.

90% of time will be spent on one or more of the following activities depending on assignments:
Review and analyze pre and post pay complex health care claims from a medical perspective, inclusive of prior authorization:
* Perform clinical review work as assigned; may provide guidance to other team members and accurately interpret and apply broad CMS guidelines to specific and highly variable situations.
* Conduct review of claim data and medical records to make clinical decisions on the coverage, medical necessity, utilization and appropriateness of care per national and local policies, as well as accepted medical standards of care.
* Review provider practices and identify issues of concern, overpayment and need for corrective action as necessary; includes surfacing potential fraud and abuse or practice concerns.
* May develop recommendations for further corrective action based on medical review findings.
* May refer for review, or implement, corrective action related to medical review activities.
* May process claims and complete project work in the appropriate computer system(s).

The remaining 10% of time will be spent on the following activities depending on assignments:
Identify providers needing education and individually educate providers who are subject to medical review processes:
* Initiate or participate in provider teaching activities, creating written teaching material, providing one on one education or education to a group as a result of a medical review (e.g., probe, progressive corrective action, consent, etc.) or appeal.
* This may involve discussion with CMS leaders and leaders in the provider community.
* Participate in special projects as assigned.

Performs other duties as the supervisor may, from time to time, deem necessary.

 

REQUIRED QUALIFICATIONS
* High School diploma or GED
* 2 years' clinical experience
* Clinical experience is any work that involves direct interaction with patients for the purpose of diagnosis, treatment, or hands-on-care
* Excellent written and oral communication skills
* Demonstrated experience with evaluating medical and health care delivery issues
* Strong computer skills to include Microsoft Office proficiency

 

CERTIFICATIONS, LICENSES, REGISTRATIONS
* Valid unrestricted Registered Nurse (RN) license

 

PREFERRED QUALIFICATIONS
* Bachelor of Science in Nursing (BSN)
* 2 years' clinical experience as a Registered Nurse (RN)
* Insurance industry experience
* Certified Coder

Background Investigation: If you are selected for this position, you must undergo a pre-employment Background Investigation, Drug Screen, and Identity Proofing documentation must be cleared prior to hire. Most positions are subject to additional Identity Proofing, Fingerprinting and additional Background Investigation screening conducted by the Federal Government to be granted Enterprise User Administration (EUA) system logical access after you begin your employment. Your continued employment is contingent upon the outcome of the complete additional screening criteria required for the position which must find that you meet the applicable government customer's requirements (e.g., suitable for access to CMS information and information systems), as well as any additional investigation which may be required throughout your employment. If you are found not suitable, your employment may be subject to corrective action, up to and including immediate termination of employment.

 

Identity Documentation: You must have access to a current and unrestricted REAL ID, U.S. Passport, U.S. Passport Card, Foreign Passport, or U.S. Permanent Residency Documents. Note: Employment Authorization Cards (EAD) are not a substitute for Visas or U.S. Permanent Resident Cards.