REGISTERED NURSE

3 weeks ago

Houston TX USA, United States US Tech Solutions, Inc. Full time
Job Description:

  • Ensures that the Local Coverage Determination (LCD) process adheres to contract instructions.
  • Creates, implements, and maintains educational tools to help providers reduce the submission of claims for non-covered services and reduce the claims payment error rate. The error rate is a factor in awarding and renewing Medicare/other contracts.
  • Provides clinical expertise, research, and judgment to develop Local Coverage Determinations (LCDS) under the direction of medical director. Maintains LCDS once developed.
  • Educates providers and internal customers on LCDS. Communicates with other interdepartmental staff in appropriate coding and reimbursement guidelines to ensure coordination and compliance.
  • Provides clinical input for internal requests. Serves as reviewer to determine inter-rater reliability.

 

Experience:


  • 7 years-clinical experience in medical insurance, managed care, case management, or claims management, or a combination of these areas. Preferred Licenses and Certificates: HIAA, Loma, and/or ACLI certification. MPH, MHA certifications.

 

Certification


  • An active, unrestricted RN license from the United States and in the state of hire, OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC). For Division 33, Certified Genetic Counsellor will be considered in lieu of RN License.

 

Skills:


  • Knowledge of managed care or medical claims payment policy issues. Working knowledge of word processing, spreadsheet software.
  • Microsoft Office. Preferred Skills and Abilities: Working knowledge of database software.
  • Knowledge of government/healthcare programs and contracts laws, regulations. Knowledge of government/healthcare programs and regulations, coding, and approval practices. Knowledge of corporate administrative/medical policy for all lines of business. Knowledge of guidelines, benefits, and coverage for all lines of business.
  • Preferred Software and Tools: Working knowledge of Microsoft Access or other database software, DB2 and Easytrieve. Work Environment: Typical office environment. Some travel required.

 

Education


  • Bachelor's degree - Nursing or other health related field. OR, associate degree in nursing with an active RN license.

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