POSITION SUMMARY: The Clinical Review Nurse is responsible for the audit and medical record review of complex medical bills in order to ensure injured workers received appropriate medical services that are medically necessary. This role is also responsible to ensure that our clients pay for all reasonable and appropriate charges.
DUTIES AND RESPONSIBILITIES:
• Bill review is responsible for clinical review, analysis, and appropriate adjustment of medical bills as needed based upon specified State bill review guidelines, other jurisdictional pricing requirements, and TRISTAR bill review protocols.
• Responsible for the audit of complex medical bills to determine appropriate use of services and charges, as well as medical necessity.
• Exercise independent judgment in communication with medical providers and assists management in identifying areas of opportunity based on current medical billing environments.
• Interacts daily with medical bill review team and provides resources to analysts and management
• Responsible for specialized pharmacy review initiative which includes the oversight and control of physician dispensed medications as well as medications that do not meet workers compensation treatment guidelines
• Communicates with providers, employers and claimants regarding disputed payments
• Evaluates and negotiates high dollar bills not subject to fee schedule or PPO reductions
• Performs other job-related duties as assigned and participates in ongoing professional development.
EQUIPMENT OPERATED/USED: Computer, fax machine, copier, printer and other office equipment
QUALIFICATIONS REQUIRED:
Education/Experience:
• Active and unencumbered professional license
• RN preferred or LPN/LVN with commensurate experience.
• Three or more years of Bill Audit experience, including knowledge of workers’ compensation laws/fee schedules in most states, and utilization guidelines as they apply to bill review
• Minimum 3 years' experience in operating room, orthopedics, ER , or other commensurate clinical experience.
• Must be a Certified Medical Coder
Knowledge, Skills and Abilities:
• Clinical experience in Operating Room, Orthopedics, Neurosurgery, ER or Occupational Health
• Excellent written and verbal communication skills including negotiating and analytical skills
• Knowledge of ICD-9, ICD-10, and CPT coding procedures
• Ability to understand state laws and regulations regarding medical bill and utilization review guidelines
• Experience with Windows (3.1 or higher), Microsoft Office, and Excel
Here is some of the benefits you can enjoy in this role:
• Medical, Dental, Vision, Disability & Life Insurance
• 401(k) plan
• Paid time off.
• Paid holidays.
Mental and Physical Requirements: [see separate attachment for a copy of checklist of mental and physical requirements]
MENTAL AND PHYSICAL REQUIREMENTS
1. MENTAL EFFORT
| a. | Reasoning development::Follow one- or two-step instructions; routine, repetitive task. |
Carry out detail but uninvolved written or verbal instructions; deal with a few concrete variables.
Follow written, verbal, or diagrammatic instructions; several concrete variables.
X Solve practical problems; variety of variables with limited standardization; interpret instructions.
Logical or scientific thinking to solve problems; several abstract and concrete variables. Wide range of intellectual and practical problems; comprehend most obscure concepts.
b. Mathematical development:
Simple additional and subtraction; copying figures, counting, and recording. Add, subtract, multiply, and divide whole numbers.
| Arithmetic calculations involving fractions, decimals, and percentages. Arithmetic, algebraic, and geometric calculations. |
Advanced mathematical and statistical techniques such as calculus, factor analysis, and probability determination.
Highly complex mathematical and statistical techniques such as calculus, factor analysis, and probability determination; requires theoretical application.
c. Language development:
Ability to understand and follow verbal or demonstrated instructions; write identifying information; request supplies verbally or in writing.
Ability to file, post, and mail materials; copy data from one record to another; interview to obtain basic information such as age, occupation, and number of children; guide people and provide basic direction.
Ability to transcribe dictation; make appointments and process mail; write form letters or routine correspondence; interpret written work instructions; interview job applicants.
| X | Ability to compose original correspondence, follow technical manuals, and have increased contact with people. |
Ability to report, write, or edit articles for publication; prepare deeds, contracts or leases, prepare and deliver lectures; interview, counsel, or advise people; evaluate technical data.
2. PHYSICAL EFFORT
| a. X | Physical activity required to perform the job:Sedentary work: Exerting up to 10 pounds of force occasionally and/or a negligible amount of force |
frequently or constantly to lift, carry, push, pull, or otherwise move objects. Sedentary work involves sitting most of the time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.
Light work:
a. Exerting up to 20 pounds of force occasionally
b. Exerting up to 10 pounds frequently
c. Exerting a negligible amount of force constantly to move objects
(If the use of arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most of the time, the job is rated for Light Work).
Medium work:
a. Exerting up to 50 pounds of force occasionally
b. Exerting up to 20 pounds of force frequently
c. Exerting up to 10 pounds of force constantly to move objects
Heavy work:
a. Exerting up to 100 pounds of force occasionally
b. Exerting up to 50 pounds of force frequently
c. Exerting up to 20 pounds of force constantly to move objects
Very heavy work:
a. Exerting in excess of 100 pounds of force occasionally
b. Exerting in excess of 50 pounds of force constantly to move objects
c. Exerting in excess of 20 pounds of force constantly to move objects
| b. | Visual requirements necessary to perform the job: Far vision: clarity of vision at 20 feet or moreNear vision: clarity of vision at 20 inches or less |
| X | |
| X | Mid-range vision: clarity of vision at distances of more than 20 inches and less than 20 feetDepth perception: the ability to judge distance and space relationships, so as to see objects where and as they actually are |
Color vision: ability to identify and distinguish colors
Field of vision: ability to observe an area up or down or to the right or left while eyes are fixed on a given point
2. PHYSICAL EFFORT (cont) FREQUENCY
c. Physical activity necessary to perform the job and frequency (e.g., continually,
frequently, or occasionally):
Climbing: Ascending ordescending ladders, stairs, scaffolding, ramps,
poles, and the like, using feet and legs and/or hands and arms. Body agility is emphasized. This factor is important if the amount and kind of climbing required exceeds that required for ordinary locomotion.
Balancing: Maintaining body equilibrium to prevent falling when walking,
standing, or crouching on narrow, slippery, or erratically moving surfaces. This factor is important if the amount and kind of balancing exceeds that needed for ordinary locomotion and maintenance of body equilibrium. Occasionally
X Stooping: Bending body downward and forward by bending spine at the
waist. This factor is important if it occurs to a considerable degree and requires full use of the lower extremities and back muscles. Occasionally
X Kneeling: Bending legs at knee to come to a rest on knee or knees. Occasionally
X Crouching: Bending the body downward and forward by bending legs and spine.
| Crawling: | Moving about on hands and knees or hands and feet. |
| X Reaching: Extending hand(s) and arm(s) in any direction.X Standing: Particularly for sustained periods of time. | |
| X Walking: | Moving about on foot to accomplish tasks, particularly for long distances.Using upper extremities top press against something with steady force in order to thrust forward, downward, or outward.Using upper extremities to extent force in order to drag, haul, or tug objects in a sustained motion. |
| X Pushing: | |
| X Pulling: | |
| FootMotion: X Lifting: | Using feet to push pedals.Raising objects from a lower to a higher position or moving |
objects horizontally from position to position. This factor is important if it occurs to a considerable degree and requires substantial use of the upper extremities and back muscles.
X Fingering: Picking, pinching, typing, or otherwise working with fingers rather
than with the whole hand or arm as in handling.
X Grasping: Applying pressure to an object with the fingers and palm.
Occasionally
Occasionally
Occasionally
Occasionally
Occasionally
Frequently
Frequently
Occasionally
2. PHYSICAL EFFORT (cont.) FREQUENCY
| X Talking: | Expressing or exchanging ideas by means of the spoken word. Those activities in which workers must convey detailed or |
important spoken instructions to other workers accurately, loudly, or quickly.
X Hearing: Perceiving the nature of sounds with or without correction.
Ability to receive detailed information through verbal communication, and to make fine discriminations in sound, such as when making find adjustments on machined parts.
Feeling: Perceiving attributes of objects, such as size, shape,
temperature, or texture by touching with skin, particularly that of fingertips.
X Repetitive Substantial movements (motions) of the wrists, hands,
Motion: and/or fingers.
Frequently
Frequently
Frequently
3. WORKING CONDITIONS
Disagreeable job conditions to which the employee may be exposed and the frequency (e.g., continually,
frequently, or occasionally) of this exposure.
WORKING CONDITION
ENVIRONMENTAL
FACTOR
NATURE/REASON
OF EXPOSURE FREQUENCY
Dirt/Dust
Noise
Temperature extremes Dampness
Vibrations
Equipment movement hazard Chemicals/solvents Electrical shock
Significant work pace/pressure Odors/Fumes
Other (specify)