Nurse Reviewer Job in Parsippany 07054, New Jersey US
Summary
One Call Medical (OCM), the nation’s leading provider of specialty services to the insurance industry, has a “smart partner” approach in delivering its suite of easy-to-use, efficient, and cost-effective ancillary services that help claims professionals to achieve superior outcomes. OCM enables injured claimants and insurance payors to get the best quality and value for diagnostic scans and electrodiagnostic testing—the building blocks for successful treatment plans and optimal return-to-work results. Through its STOPS subsidiary, the company provides transportation and language services, required by today’s increasingly diverse claimant population; and through its Express Dental Care subsidiary, OCM assists with all aspects of the dental claims management process, as well as handling referrals to hearing, eye, and other hard-to-find specialty providers. OCM’s customers include the nation’s leading insurance companies, third-party administrators, payors, and self-insured employers. OCM is currently seeking a full-time Provider Product Manager for its Specialty Programs Group.
Responsible for the Clinical Review of Medical Reports and HCFA/Bills for EMG NCS in assigned states; Clinical Review of Sample reports and Quality Reviews; Processing of Aging reports; Clinical Resource to payers, providers and employees
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.
Performs accurately, timely and completely Initial Clinical Review of EMG NCS medical reports and HCFA/Bills, including
- Completes Physician Report Cards, including parts 1, 2 and 3a.
- Obtains data/documentation to complete bills, including NCS data, EMG muscles sheets, consultation documentation, and/or corrections;
- Documents actions, including phone calls, faxes and/or letters in database(s).
- Performs follow-up on requests for additional information/corrections to Medical Reports;
- Evaluates results and determines if test results are Normal or Abnormal;
- Demonstrates knowledge of ICD-9 codes and prioritizes diagnosis codes in database and documents on MRR form;
- Assesses count of muscles and nerves accurately and completely;
- Demonstrates knowledge of CPT codes;
- Performs Coding including Allowed Codes, Disallowed Codes and Explanation Codes
- Develops Bill Query faxes to providers and performs follow-up in timely manner;
- Receives Medical Report Review forms from Physician Reviewer(s) and takes action(s) as directed;
- Verbalizes knowledge of appeal process for providers, payors and their office staff;
- Manages Provider and Payor appeal process. Coordinate Appeals, including review of appeal for content, letters returning incomplete Appeal with Policy Procedure, completion of Appeal form(s), mailings to Medical Director and/or Medical Board Consultants, statistical documentation, and reply form letters.
Performs review of radiology reports for Aging Product.
- Processes Aging reports under supervision of Radiology Advisory Board, primarily for radiology reports from Florida and New York.
- Review of radiology terminology on the report for acute, chronic and/or indeterminate abnormal findings
- Documents actions during workflow in database.
- Documents outcomes and method is completed in database.
- Organizes work through use of database reports.
- Determines need for medical report addendum due to lack of aging documentation.
- Assigns addendum needed to Product Specialist per their state assignments
- Responds to questions from payers /Sales Team/ internal employees on the aging product.
- Enhances the aging templates with additions and revisions
Performs review of EMG NCS Sample Medical Reports for Clinical Review Process in assigned states, including:
- Performs medical report review of all reports identified by “In Clinical Review”;
- Identifies sample medical reports and documents in database;
- Documents sample medical reports reviewed in database;
- Receives Medical Report Review forms from Physician Reviewer(s) and takes action(s) as directed;
- Completes “Clinical Review File Completion Report” when three abnormal sample reports are reviewed;
- Suspends providers and notifies supervisor of critical errors, including no amplitudes and no data immediately upon completing review;
- Documents actions, including phone calls, faxes and/or letters in database(s).
- Coordinates presentation of providers to Credentialing Committee including submission of agenda items to supervisor and paperwork preparation.
- Collaborates with Product Specialist for preparation and letters and documents to send to provider.
- Verbalizes knowledge of credentialing process to providers and their office staff;
Performs Quality Reviews on EMG NCS medical reports for payers when the test was not scheduled by One Call Medical under the direct supervision of OCM’s Neurodiagnostic Medical Director.
Investigates and completes EMG NCS complaints under direct supervision of Neurodiagnostic Medical Director, including follow-up and documentation for assigned states/geographic regions.
Coordinates Quality Improvement (QI) functions for Neurodiagnostic product in assigned states/geographic regions.
- Develops and implements QI Plan for assigned states;
- As assigned by Medical Director and/or supervisor, performs QI functions;
- Notifies supervisor of suspended providers and implements second level reviews;
- Presents suspended providers at QI Committee Meetings;
- Presents appropriate form letters (Standards, Temperature and/or Radiculopathy) to supervisor for approval;
- Documents actions and responses;
- Performs follow-up to letters;
- Verbalizes knowledge of Quality Improvement process to providers, their office staff, colleagues and staff of other departments;
- Provider educational opportunities to providers, provider’s billing staff, colleagues and staff of other departments
- Contributes to process improvement of Clinical Services Department and other departments.
- Completes audits, as assigned.
Utilizes and maintains general knowledge of insurance reimbursement and specific knowledge of OCM processes.
Utilizes and maintains knowledge of American Association of Neuromuscular Electrodiagnostic Medicine (AANEM) Guidelines, CPT and ICD-9 coding, HCFA, and Neurodiagnostic studies.
Responds to Clinical Questions from internal (employees) and external (adjusters, Nurse Case Managers and providers) sources while adhering to the department’s policies and procedures, especially “Clinical Tools”.
Utilizes and maintains knowledge of radiology product as demonstrated through use of clinical tools such as American College of Radiology guidelines criteria, ACR Coding, CPT and ICD-9 coding, departmental CPT coding worksheets, CMS CCI edits. Performs research on diagnostic radiology procedures, as assigned. Completes medical report audits, as assigned..
Adheres to departmental standards and contributes suggestions for improvement of policies and procedures.
Keeps supervisor informed, especially concerning training opportunities for colleagues and other departmental staff.
Bachelor’s degree (BSN) from four year college or university or equivalent work experience. Five years work history in medical field including minimum of three as R.N. Experience should include functioning within the standards of the Nurse Practice Act for Registered Nurses in the State of New Jersey with demonstration of current knowledge of nursing process and the ability to perform retrospective analysis of medical reports. Experience should include teaching, explanation of educational/marketing materials, and analysis of data.
One Call Medical offers competitive pay and a full benefits package. Please submit cover letter and resume with salary requirements to www.onecallmedical.com EOE