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Professional Review Nurse

Company: CorVel
Location: Austin
Posted on: November 19, 2021

Job Description:

GENERAL DESCRIPTION: The Professional Review Nurse provides analysis of medical services to determine appropriateness of charges on multiple types of medical bills and review of medical reports to determine appropriateness of medical care. Clinical and/or technical expertise is utilized to address the provision of medical care and to identify inappropriate billing practices and errors inclusive of, but not limited to; duplicate billing, unbundling of charges, services not rendered, mathematical and data entry errors, undocumented services, reusable instrumentation, unused services and supplies, unrelated and/or separated charges, quantity and time increment discrepancies, inconsistencies with diagnosis, treatment frequency and duration of care, DRG validation, service/treatment vs. scope of discipline, use of appropriate billing protocols, etc. This position is fully remote. ESSENTIAL JOB DUTIES: The Professional Review Nurse must: * Identify the necessity of the review process and communicate any specific issues of concern to the claims examiner/client and or direct reporting manager * Collect supporting data and analyze information to make decisions regarding appropriateness of billing, delivery of care and treatment plans * Completely document work and final conclusions in designated computer program * Adhere to regular and consistent work attendance * Comply with all safety rules and regulations during work hours in conjunction with the Injury and Illness Prevention Program (IIPP) and other requirements as outlined in the Employee Handbook * Be responsive to additional Professional Review job duties as assigned by management or determined by legislative changes and/or market changes REQUIRED EDUCATION/TRAINING: Must maintain current licensure as a Registered Nurse in the state of employment with a minimum of 4 years clinical experience. Must be computer literate. PREFERRED EDUCATION/TRAINING: The Professional Review Nurse should have a minimum of an Associate Degree in Nursing and have a thorough knowledge of both C.P.T. and I.C.D.9 codes. Previous experience in the following areas is beneficial: * Medical bill auditing * Experience in the clinical areas of O.R., I.C.U., C.C.U., E.R., and orthopedics. * Knowledge of worker's compensation claims. * Prospective, concurrent and retrospective utilization review. COMMUNICATION REQUIREMENTS: Must be able to communicate concisely and effectively in writing and verbally. Must have the ability to interface with the claims adjusters, attorneys, physicians and their representatives, and advisors/clients, and co-workers. About CorVel CorVel, a certified Great Place to Work-- Company, is a national provider of industry-leading risk management solutions for the workers' compensation, auto, health and disability management industries. CorVel was founded in 1987 and has been publically traded on the NASDAQ stock exchange since 1991. Our continual investment in human capital and technology enable us to deliver the most innovative and integrated solutions to our clients. We are a stable and growing company with a strong, supportive culture and plenty of career advancement opportunities. Over 3500 people working across the United States embrace our core values of Accountability, Commitment, Excellence, Integrity and Teamwork (ACE-IT!). A comprehensive benefits package is available for full-time regular employees and includes Medical (HDHP) w/Pharmacy, Dental, Vision, Long Term Disability, Health Savings Account, Flexible Spending Account Options, Life Insurance, Accident Insurance, Critical Illness Insurance, Pre-paid Legal Insurance, Parking and Transit FSA accounts, 401K, ROTH 401K, and paid time off. CorVel is an Equal Opportunity Employer, drug free workplace, and complies with ADA regulations as applicable.

Keywords: CorVel, Austin , Professional Review Nurse, Healthcare , Austin, Texas

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