Nurse Sr Professional Job in Nashville, Tennessee US
Job Title: Nurse Sr ProfessionalJob Number: 09009GNJob Category: Health CarePrimary Location: USA-TN: TENNESSEE-NASHVILLESchedule: Full-timeJob Type: RegularEmployee Status: RegularJob Posting: 2009-Sep-03 DescriptionEssential Job Functions Conducts clinical reviews of medical records during the course of fraud investigations or other benefit integrity initiatives such as requests for information or in support of proactive data analysis.
Applies Medicare guidelines in making clinical determinations as to the appropriateness of payment coverage.
Reviews information contained in Standard Claims Processing System files (e.
g., claims history, provider files) to determine provider billing patterns and to detect potentially fraudulent or abusive billing practices or vulnerabilities in Medicare payment policies.
Utilizes extensive knowledge of medical terminology, ICD-9-CM, HCPCS Level II and Current Procedural Terminology (CPT) coding along with analysis and processing of Medicare claims.
Coordinates and compiles a written Investigative Summary Report upon completion of the records review.
Provides expert witness testimony as required.
Qualification Basic Qualifications Graduate from an accredited school of nursing and has an active license as a Registered Nurse (RN) Must have no adverseactions pending or taken against him/her by any State or Federal licensing board or program; andmust have no conflict of interest (COI) as defined in 1154(b) (1) of the Social Security Act. Must have and maintain a valid driver's license by his/her state of residence.
At least 5 years utilization / quality assurance review and ICD-9-CM/CPT coding experience DRG codes.
Knowledge of, and the ability to correctly identify, Medicare coverage guidelines.
Other Qualifications Communication skills Ability to use Microsoft Word, Excel, Internet applications and databases Previous Medicare experience preferred Organization and time management skills Leadership skills to guide and mentor the work of less experienced personnel Ability to work in a team environment Ability to keep sensitive and confidential material private Willingness to travel Remote Work Location Authorized: No Relocation Assistance: Not Available Clearance Level: None
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