TDY Medical Staffing, Inc. is currently seeking Medical Review Nurses for a contract temp to perm 6 month contract position located in Pittsburgh, PA area. This is a Monday - Friday Day Shift position 8a-4p. Please do NOT apply if you are not willing to work forty hours per week. Once you apply, please check your email as we will communicate with you via this means.
Must have computer experience.
Please submit a resume with 3 professional references - please list your skills online in the area provided after you hit the APPLY button. If you do not submit a resume with professional references, you will not be considered for employment.
The Clinical Review Nurse is responsible for reviewing and making medical determinations as to the validity of health claims and levels of payment in meeting national and local policies as well as accepted medial standards of care. The incumbent applies clinical knowledge to assess the medical necessity, level of services and appropriateness of care which may include cases requiring prospective, concurrent or retrospective utilization review.
ESSENTIAL DUTIES AND RESPONSIBILITIES: Review and analyze pre and post pay complex health care claims from a medical perspective:
Perform clinical review work as assigned; may provide guidance to other staff members and accurately interpreting and applying broad CMS guidelines to specific and highly variable situations Conduct review of claim data and medical records to make clinical decisions on the coverage, medical necessity, utilization and appropriateness of care per national and local policies as well as accepted medical standards of care May process claims and complete project work in the appropriate computer system(s) Review provider practices and identify issues of concern, overpayment and need for corrective action as necessary; including surfacing potential fraud and abuse or practice concerns May develop recommendations for further corrective action based on medical review findings May refer for review, or implement, corrective action related to medical review activities May identify providers needing education and individually educate providers who are subject to medical review processes 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 (e.g., probe, progressive corrective action, consent, etc.) This may involve discussion with CMS leaders and leaders in the provider community. Participate in special projects as assigned
Performs other duties as the supervisor may, from time to time, deem necessary.
3 or more years of clinical experience Excellent written and oral communication skills Demonstrated experience with evaluating medical and health care delivery issues Strong computer skills to include Microsoft Office proficiency
Current Clinical Licensure:
Associate's Degree Bachelor's degree in Nursing, Master's degree, or equivalent clinical degree
Experience using claims processing system (e.g., MCS/FISS), etc. A strong understanding of coding systems such as ICD-9, HCPCs, CPT-4 and APC
Licenses or Certifications:
Certified Professional Coder/Certified Professional Utilization Reviewer
Certification in or equivalent training in a medical specialty (e.g., cardiology, emergency room,
TDY Medical Staffing, Inc. is an Equal Opportunity Employer and takes pride in maintaining a diverse environment. All qualified applicants will receive consideration for employment without regard to their race, color, religion, gender, gender identity, national origin, age, sexual orientation, marital or protected veteran status, disability, or any other legally protected status. If you’d like more information about your EEO rights as an applicant under the law, please click here
Once you hit the “Apply Now” button, you will be directed to enter into your information into our website general application – There will be several questions asked to ensure our Affirmative Action/EEOC compliance. Your participation is voluntary and will have no impact on the interview process.
TDY is a federal contractor and as such is required to provide self-identification questions regarding race/gender/disability/veteran status to all qualified applicants. We offer all applicants the VOLUNTARY opportunity to respond to the questions.
You are under no obligation to respond to the questions and not answering the questions will have no impact on the application process or hiring decisions. Your responses are not seen by the hiring authority and have zero impact on our decision making process. Submitting this general application is not an offer of employment and does not a guarantee that the application process will proceed.