Utilization Review Nurse
4 weeks ago
Job Summary
+ The Medical Records Utilization Case Manager will support documentation of medical necessity by facilitating medical records (MR) collection and client outreach, by offering expert review and interpretation on a case by case basis, and by maintaining collaborative and productive relationships within the organization relating to Revenue Cycle Management.
Job Responsibilities:
+ Successfully obtain necessary medical documentation by collaborating with and serving as a primary liaison between in-house billing operations, customer experience groups and clinic medical records departments
+ Have a thorough understanding and knowledge of applicable CMS, state, and insurer medical policy and coverage guidelines (in particular LCD & NCD Coverage Criteria)
+ Ability to navigate and extract data from multiple versions of electronic medical records, including EPIC
+ Serve as a source of knowledge for medical records (MR) review and interpretation, including in-depth review of provider progress notes and charts with the ability to identify critical data points highlighting why patient criteria meets medical necessity and summarizing in a succinct manner for health insurance companies
+ An in-depth knowledge and understanding of oncology and organ health terminology (including chemotherapy treatments and well as immunotherapy treatments)
+ Develop and cultivate ongoing working relationships with other departments impacting revenue cycle performance
+ Participate in weekly meetings, daily discussions, case reviews and continuing education to review key metrics, workflows, trends, and performance improvement opportunities
+ Prioritize performance initiatives and ensure productivity goals are achieved within a timely manner while maintaining the highest quality of work standards for Q/A
+ Follow department procedures and ensure all activities are documented and conducted within compliance standards with applicable business process requirements and regulatory requirements
+ This role requires access to Patient Health Information (PHI) both in paper and electronic form. Therefore, employees must complete training relating to HIPAA & PHI privacy, General Policies and Procedure Compliance training and security training as a requirement of the job
About TEKsystems:
We're partners in transformation. We help clients activate ideas and solutions to take advantage of a new world of opportunity. We are a team of 80,000 strong, working with over 6,000 clients, including 80% of the Fortune 500, across North America, Europe and Asia. As an industry leader in Full-Stack Technology Services, Talent Services, and real-world application, we work with progressive leaders to drive change. That's the power of true partnership. TEKsystems is an Allegis Group company.
The company is an equal opportunity employer and will consider all applications without regards to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.
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