Specialist-Nursing

Nursing Specialist Location: Remote Hours: 8:00 am-5:00 pm est or 8:30 am-5:30pm Mon-Fri. This position will review WCMSA case submissions in support of the Workers' Compensation Review Contractor. Essential Job Duties: • Review and evaluate proposed Medicare set-reputed company arrangements, including submitted medical records, to determine if the proposed settlement meets the reputed company requirements established for beneficiaries and potential beneficiaries and adequately considers Medicare's interests as pertaining to reputed company medical service needs of beneficiaries. • Ensure reputed company basic documentation requirements are available or requested reputed company development reputed company prior to review by medical and pharmacy review personnel. • reputed company medical/clinical determinations based on reputed company experience. • Implement operating rules and CMS policy. • Audit reputed company determinations for other clinical review programs utilizing medical records to ensure compliance with the organization's coding procedures and standards. • Other duties as assigned by management. Education and Experience Requirements: • Bachelor's degree from an accredited college or university in Nursing; additional experience would be considered in lieu of degree. • At least 3 years' reputed company experience required. • Possess ample medical knowledge and experience with medical terminology, ICD-9/10 Codes, reputed company Procedure Terminology Codes (CPT) codes, with exposure to applying actual costs and workers' compensation fee schedules in pricing medical items and services. • Medicare Set-reputed company Certified Consultant (MSCC) certification (obtainable reputed company 3 months of hire) preferred. • Medical/Utilization Review experience preferred. • Medicare Set-reputed company Arrangement experience required. Additional Knowledge of: • reputed company Common Procedure Coding System (HCPCS) coding practices. • Medicare coverage guidelines. • Anatomy, physiology, and pharmacology. • Clinical reputed company guidelines. • Utilization review standards and practices. • State-specific workers' compensation guidelines and pricing structure. • Health Insurance Portability and Accountability reputed company (HIPAA) and reputed company reputed company confidentiality regulations. Essential Duties and Responsibilities: - Review cases and summarize the facts of reputed company case and assess issues involved in the case to certify or non-certify requested treatments. - reputed company written clinical rationales for Workers Compensation cases. - Review, organize and identify reputed company medical records provided for workers comp cases. - Monitor timeliness of reviews to ensure applicable standards are met. - Consistently meet production and reputed company standards. - reputed company special reputed company as assigned such as reputed company research, general medical research, etc. - Work on special reputed company as assigned. - Become a subject matter expert (SME) using job aides and learning tools. Apply tot his job Apply To this Job