REMOTE Registered Nurse - Medical Review Specialist-Bexar County, Texas

Avosys Technology, Inc; San Antonio (TX); Remote; USD 60,000 - 100,000; Full time

Job summary

An established industry player is looking for a Remote Registered Nurse - Medical Review Specialist to join their team. In this role, you will conduct clinical reviews of Medicare claims, ensuring compliance with CMS guidelines while maintaining a work-life balance with no weekend or holiday shifts. This position offers guaranteed 8-hour shifts and a comprehensive benefits package, including medical, dental, and 401(k). If you are passionate about healthcare and want to make a difference while enjoying flexibility and a supportive work environment, this opportunity is perfect for you.

Benefits

Competitive benefits package

Medical insurance

Dental insurance

Vision insurance

Life insurance

Short-term disability

Long-term disability

401(k) plan

Flexible working hours

Qualifications

• Minimum of two years clinical experience required.
• Strong communication skills are essential for this role.

Responsibilities

• Perform clinical reviews of Medicare claims per CMS requirements.
• Document clinical decisions and ensure compliance with Medicare regulations.

Skills

Clinical experience

Written communication skills

Oral communication skills

Evaluating healthcare delivery issues

Microsoft Office proficiency

Education

Registered Nurse license

Tools

Electronic decision template

Provider tracking system

Job description

Overview

Avosys is a growing integrator of professional, technological and management solutions services. Founded in 1998, Avosys provides services nationwide to Federal, Commercial, Local and State clients. We recognize the foundation of our firm is our people and we continue to rise above our competition by hiring the best.

Avosys is seeking a Bexar County Remote Registered Nurse - Medical Review Specialist to work remotely to review Medicare claims..

• Maximize family time with no weekend, Holiday, or on-call requirements
• Maintain work-life balance with guaranteed 8-hour shifts
• Take advantage of our competitive, comprehensive benefits package including medical, dental, vision, life, short-term disability, long-term disability & 401(k)

Responsibilities

• Perform clinical reviews of Medicare Part A and Part B claims for Medical Review, Redeterminations/Appeals (Appeals), and Prior Authorization requests (collectively, the “Services”) in accordance with CMS (Centers for Medicare & Medicaid Services) requirements
• Complete a projected number of clinical review hours while meeting timeliness and accuracy standards and completing documentation of clinical decisions for remittance.

Clinical review of services

• Review medical record documentation within CMS timeliness parameters (i.e., 20 days from receipt of the medical record for pre-payment reviews and 50 days from receipt of the medical record for post payment reviews)
• Utilize the applicable Medicare policies (i.e., Local Coverage Determinations, National Coverage Determinations, Internet-Only Manual (IOM) citations, inpatient tools, etc.) to ensure the services comply with all Medicare regulations and documentation requirements
• Review documentation for medical necessity per guidelines outlined in the Social Security Act 1862(a)(1)
• Ensure that all documentation includes a valid signature consistent with the signature requirements

Documentation of rationale for processing decisions

• Provide a claim sample of three (3) claims to Companies via established protocols and timeliness parameters (i.e., 18 days from receipt of the medical record for pre-payment reviews and 48 days from receipt of the medical record for post payment reviews) for quality review prior to finalization of documentation of reason for payment, reduction, or denial of service to ensure accuracy of claim decision making
• Companies will review the three-claim sample for accuracy of claim decision and will make and return decisions to the MRS within 24 hours or less
• Complete the documentation of the reason for payment, reduction, or denial of service for all claims on an electronic decision template to be provided by Companies. This rationale must be in sentence format so that it may be inserted directly into the response to the provider, must be clear and well-written, and contain sufficient information to educate the providers on how the review decision was made
• Return documented decision electronically to Companies via established protocols and timeliness parameters (i.e., 20 days from receipt of the medical record for pre-payment reviews and 50 days from receipt of the medical record for payment reviews)
• Complete the review results letter in the Companies’ letter writing system within 35 days from receipt of the medical record for pre-payment reviews and no later than 60 days from receipt of the medical record for post payment reviews
• Document all case activity in Companies’ provider tracking system on the day the activity occurs
• Complete one-on-one provider education (i.e., webinar, conference call, etc.) within 30 days of sending out review results letter
• Respond to provider inquiries related to case and/or claims throughout the course (i.e. in 24 hours or less) of review
• If additional clinical guidance is required, complete the Contractor Medical Director (“CMD”) assistance form, track response, and update review accordingly
• Conduct telephone development for missing or additional records for easily curable errors
• Notate date of receipt of additional documentation received in the Companies’ provider tracking system
• Upon request by Companies, initiate or participate in provider teaching activities, creating written teaching material, providing one-on-one education or education to a group as a result of an MR review
• If fraud activity is suspected, immediately complete initial referral packet for external entity referral and return the packet to the Companies
• Complete referrals to Companies’ provider outreach and education (“POE”) area in provider tracking system for cases that have a moderate or major error rate
• Lead and Alternate Lead will participate in all monthly departmental training and meetings, and all Staff will participate as requested
• Submit all cases for review and approval for quality and closure of cases

Qualifications

• Minimum of two (2) years’ clinical experience
• Excellent written and oral communication skills
• Demonstrated experience with evaluatingmedical and health care delivery issues
• Strong computer skills to include Microsoft Office proficiency

License - Certifications

• Active and current Registered Nurse license

Other Information

Industry: Defense

US Citizenship Required: Yes

Background Check: Required

Current Clearance Level Required: None

Telework: Yes but Resides in Bexar County, Texas

Travel: No

Equal Opportunity Employer/Veterans/Disabled

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, gender identity, national origin, or protected veteran status and will not be discriminated against on the basis of disability. If you are an individual with a disability and require a reasonable accommodation to complete any part of the application process, or are limited in the ability or unable to access or use this on-lineapplication process and need an alternative method for applying, you may contact [phone] or [e-mail] for assistance.