Nurse 3

State-of-West-Virgini; West Virginia; On-site; USD 65,000 - 90,000; Full time

Job summary

State-of-West-Virgini seeks a nurse reviewer to perform pre- and post-payment Medicaid service reviews, assessing medical necessity and documentation against policy. You will serve as lead on complex cases and prepare reports for the Medicaid program administrator.

Requirements include a nursing degree with WV license, several years of nursing experience and professional certification preferred; strong communication with providers and the ability to develop procedures with program staff.

Qualifications

• Nursing education with WV licensure or temporary permit.
• Experience in Medicaid program policy and coding preferred.
• Ability to develop and update medical review procedures.

Responsibilities

• Perform pre-payment and post-payment reviews of Medicaid services to assess accuracy.
• Determine medical necessity and adherence to policy and documentation.
• Provide written reports to the Medicaid program administrator.
• Communicate with medical practitioners on policy coverage and coding matters.
• Develop Medicaid procedures in coordination with program staff.

Skills

Medical review

Analytical thinking

Communication

Education

Baccalaureate nursing degree

Diploma or associate nursing degree

Nursing certification (specialty)

Associate degree in nursing or health sciences

Master's degree in nursing

Job description

Under general supervision, this resource will perform the following duties and functions: Perform pre-payment and post-payment reviews of Medicaid services, from a medical standpoint on a wide variety of providers to determine accuracy of claims submitted, documentation requirements being met, medical necessity criteria and adherence to Medicaid policy. Serve as lead person to identify medical necessity for the service and/or procedure, areas of concern and course of action needed. Provide written reports to the program administrator of the Medicaid program assessed Regarding compliance with program policy. Communicate with medical practitioners/ facilities verbally and in writing on Medicaid program policy coverage and procedure coding matters. Development of Medicaid program and procedures in coordination with program staff. Review and update procedure editing criteria. Independently evaluate medical services and specialized Plans of care. Coordinates with other medical Professionals in evaluating appropriate treatment of Medicaid recipients. Perform professional medical review of treatment practice and patient utilization patterns are reflected in profiles generated by the Medicaid claims processing system, serve on the selection team in determining what providers to review. Provide recommendations regarding program deficiencies and educational needs. Identify, develop, implement and utilize technical criteria for reviewing, and evaluating medical necessities. This position will also perform other duties needed to support the office and Bureau as assigned.

Training:

• Baccalaureate degree in nursing from an accredited four-year college or university and two years of full-time or equivalent part-time paid experience as a registered professional nurse.
• Successful completion of an associate degree in nursing from an accredited college or university or a diploma nursing program and three years of experience as a registered professional nurse.
• Professional certification from a recognized national nursing certifying organization as a nurse or nurse practitioner in the area of assignment plus two years of full-time or equivalent part-time paid experience as a registered professional nurse.
• Successful completion of an associate degree in nursing from an accredited college or university or a diploma nursing program; plus baccalaureate degree in the health sciences or behavioral sciences and two years of full-time or equivalent part-time paid experience in nursing.
• Master's degree in nursing from an accredited four-year college or university.

Special Requirement:

Current West Virginia license or temporary permit to practice as a registered professional nurse.