- 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
- Completely document work and final conclusions in designated computer program
- Adhere to regular and consistent work attendance
- Comply with all safety rules and regulations during work hours in conjunction with the Injury and Illness Prevention Program (IIPP) and other requirements as outlined in the Employee Handbook
- Responsive to additional Professional Review job duties as assigned by management or determined by legislative changes and/or market changes
- Must be able to communicate concisely and effectively in writing and verbally
- Must have the ability to interface with the claims adjusters, attorneys, physicians and their representatives, and advisors/clients, and co-workers
- Must have the ability to effectively promote all Professional Review products with attorneys, claims examiners, customers and management
- Must also have a strong ability to negotiate provider fees effectively
- Must be computer literate
- 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.10 codes is preferred
- 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
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Professional Review Nurse - Texas, United States - CorVel Corporation
Description
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. Clinical and/or technical expertise is utilized to address the provision of medical care and to identify inappropriate billing practices and errors inclusive of, but not limited to; 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.
ESSENTIAL FUNCTIONS & RESPONSIBILITIES:
KNOWLEDGE & SKILLS:
EDUCATION & EXPERIENCE:
PAY RANGE:
CorVel uses a market based approach to pay and our salary ranges may vary depending on your location. Pay rates are established taking into account the following factors: federal, state, and local minimum wage requirements, the geographic location differential, job-related skills, experience, qualifications, internal employee equity, and market conditions. Our ranges may be modified at any time.
Pay Range: $49,359 – $79,603
A list of our benefit offerings can be found on our CorVel website: CorVel Careers | Opportunities in Risk Management
About CERIS
CERIS, a division of CorVel Corporation, a certified Great Place to Work Company, offers incremental value, experience, and a sincere dedication to our valued partners. Through our clinical expertise and cost containment solutions, we are committed to accuracy and transparency in healthcare payments. We are a stable and growing company with a strong, supportive culture along with plenty of career advancement opportunities. We embrace our core values of Accountability, Commitment, Excellence, Integrity and Teamwork (ACE-IT).
A comprehensive benefits package is available for full-time regular employees and includes 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.
CorVel is an Equal Opportunity Employer, drug free workplace, and complies with ADA regulations as applicable.
