CERIS Professional Review Nurse I - Los Angeles - CorVel

    CorVel
    CorVel Los Angeles

    1 week ago

    Description

    CERIS Professional Review Nurse I

    The CERIS 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. This is a remote position.

    Essential Functions & 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
    • 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

    Knowledge & Skills:

    • 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

    Education & Experience:

    • 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

    Pay Range: $47,061 $70,236

    A list of our benefit offerings can be found on our CorVel website: CorVel Careers | Opportunities in Risk Management

    CorVel is an Equal Opportunity Employer, drug free workplace, and complies with ADA regulations as applicable.

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