Nurse Review Coordinator

Job Description

Job Description

Description : JOB SUMMARY

JOB SUMMARY

The Nurse Review Coordinator for Value-Based RCM, Inc. (VBRCM) is a licensed practical nurse responsible for helping secure pre-service authorizations.

MAJOR AREAS OF FOCUS

• Clinical Coverage Review
• Pre-service authorization

RESPONSIBILITIES

• Serve as the main escalation point of contact for clinical service reviews.
• Communicate with the client regarding medical necessity and review criteria.
• Verify member insurance eligibility and benefits.
• Review and process urgent and non-urgent authorization requests (via phone, fax and electronic submission) for medical necessity (according to established criteria) and authorize, pend or modify as appropriate.
• Obtain additional medical information as necessary from requesting provider.
• Provide accurate and complete documentation with rationale used to approve request.
• Provide clinical knowledge and act as a clinical resource to non-clinical team staff.
• Assist in preparing documentation, performing audits of patient records, and helping management with tasks as needed.
• Review pre-service denials to determine additional information needed to appeal or perform peer to peer.
• Collaborate with various staff within provider networks and case management team electronically.
• Participate in on-call or alternate work hour programs as needed to meet regulatory compliance requirements.
• Develop and update health plan resources and forms.
• Provide training to new hires and continuous education to utilization management team.
• Enter and maintain authorization information in multiple health management systems.

Requirements : KNOWLEDGE AND SKILLS

KNOWLEDGE AND SKILLS

• Knowledge of ICD-10 and CPT coding.
• Excellent verbal and written communication skills.
• Ability to work effectively with a variety of customers, including but not limited to providers and office staff.
• Ability to work independently with self-initiative and discipline.
• Ability to demonstrate respect and sensitivity for culturally diversity within VBRCM and our customers.
• Optimum organizational skills with ability to meet expected and unexpected time frame.
• Ability to work autonomously to resolve issues in a timely manner.
• Ability to work in a team-based environment to accomplish goals and objectives.
• Strong service orientation and professionalism.
• Working knowledge of personal computers.EDUCATION / EXPERIENCE
• Minimum of a licensed practical nursing (LPN) certification with two or more years of clinical nursing experience.
• Experience with medical necessity reviews and coverage determinations.
• 1-2 years of Utilization Management experience preferred.
• Managed care experience preferred.

PHYSICAL REQUIREMENTS

Prolonged periods sitting at a desk and working on a computer

Must be able to lift up to 15 pounds at times

JOB TYPE : Full-time

HOURLY RATE : $24-$30 per hour

JOB LOCATION : Remote

BENEFITS :

• Flexible paid time off
• Work from home
• 401K with company match
• Company-sponsored medical, dental, and vision insurance
• Company-paid life insurance, short-term disability, and long-term disability

SCHEDULE :

• Monday to Friday
1 day ago