TMF Health Quality Institute and C2C Innovative Solutions, Inc. are Equal Opportunity Employers (Minorities/Females/Vet/Disability)

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2017:115: Record Review/Prepayment Nurse I
Position Code:2017:115
Team:Surveillance and Utilization Review Services
Location:Austin, TX
  
Job Responsibilities:
Position Purpose:
Performs moderately complex (journey-level) work.  Conducts contract activities in accordance with state agencies and the state policies and requirements.  Works under general supervision, with moderate latitude for the use of initiative and independent judgment.
 
Essential Responsibilities:
• Obtains and reviews medical records to determine compliance with review and program policies.
• Documents review findings and recommends adjustments or denials of services for each claim detail.
• Obtains physician/dentist decisions on medical necessity-related findings.
• Composes narrative summary of record review findings and writes education or recoupment letters as directed.
• Communicates directly with State customer.
• Performs actions for case disposition which may include:  initiating claims payment recoupment of denied or adjusted services; conducting provider education; or performing prepayment review and adjudicating claims based on results of record review.
• Documents and tracks provider case review activities and case dispositions, and prepayment review activities. 
• Performs reviews of cases referred from state agencies and prepares report of findings. 
• Reviews and processes appeals.
• Participates in special projects and performs other duties as assigned.
Job Qualifications:

Minimum Qualifications
 
Education
• Diploma Nurse or Associates degree in nursing or related discipline from an accredited college or university

License and Certification
• Registered Nurse (RN) with an active Texas license
• Coding Certification, preferred

Experience
• Three (3) years healthcare
• Two (2) years clinical in a healthcare setting
• One (1) year utilization management, retrospective review, medical record review, or claims review

Knowledge, Skills and Abilities

Working knowledge of
• Research techniques
• Medical terminology
• Applicable laws, rules and regulations

Proficient skill in
• Preparing correspondence/documents using correct spelling, grammar and punctuation; proofreading and reviewing documents for clarity and consistency
• Prioritizing and organizing work assignments
• The use of personal computers and applicable programs, applications and systems

Some skill in
• Researching, analyzing and interpreting policies and state and federal laws and regulations

Ability to
• Exercise logic and reasoning to define problems, establish facts and draw valid conclusions
• Make decisions that support business objectives and goals
• Identify and resolve problems or refer issues appropriately
• Communicate effectively verbally and in writing
• Adapt to the needs of internal and external customers
• Show integrity and ethical behavior; respect confidentiality, business ethics and organizational standards
• Assure compliance with regulatory, contractual and accreditation entries

Work Environment
Requires working in an office/cubicle environment; sitting, standing, walking, bending, twisting and/or reaching. Requires repetitive movement; ability to lift, carry or move up to 25 lbs. when transporting work equipment or materials.  May require ability to operate a motor vehicle; the ability to travel by motor vehicle and commercial airline.  May require overnight travel.