TMF Health Quality Institute
PLEASE VISIT OUR CAREER CENTER TO APPLY!
This position will require 4-6 months of training in an office setting, after the training is complete this position can be remote.
Expectation for All Employees
Support the organization’s mission, vision and values by exhibiting the following behaviors: model integrity, embrace innovation, celebrate success, strive for excellence, focus on those we serve and foster trust.
Perform medical record review as required by contracts. Make sound, independent decisions based on submitted evidence in accordance with statutes, regulations, rulings, and Centers for Medicare & Medicaid Services (CMS) policy. Manage review caseload. Coordinate with customer and staff. Create accurate, clearly stated letters to beneficiaries and providers.
- Perform various types of medical record review by specific contracts including, but not limited to, appeal review for Medicare Administrative Contractor (MAC) and Qualified Independent Contractor (QIC) contracts.
- Complete review of cases in accordance with guidelines and regulations.
- Provide a fair and impartial decision.
- Write clear and concise letters that support determination made.
- Manage workload to assure adherence to timelines and productivity goals.
- Apply approved state and national criteria in determining medical necessity for hospital admission and healthcare services.
- Prepare correspondence to healthcare providers, physicians and/or beneficiaries using proper grammar, the appropriate template and including all required components.
- May assist in daily work assignment for review staff.
- May assist in training and serve as preceptor for new employees.
- May serve as clinical and technical resource for other staff members.
- Document and track case review activities and case disposition within required time frames.
- May perform quality control assessment.
- May serve as point of contact in working with customer to resolve issues related to systems access.
- Use computers to enter, access or retrieve data.
- Identify and resolve problems or refer issues appropriately.
- Communicate effectively with internal and external customers.
- Adapt to the needs of internal and external customers.
- Assure compliance with regulatory, contractual and accreditation entities.
- Maintain strict adherence to confidentiality and security policies and procedures.
- Participate in special projects and perform other duties as assigned.
Requires sitting; Requires standing; Requires walking; Requires bending, twisting or reaching; Requires using hands to handle, control, or feel objects, tools or controls; Requires repetitive movement; Requires typing; Requires use of electronic mail; Requires writing letters and memos; Requires contact with others (face-to-face, by telephone, or otherwise); Requires work with others in a group or team; Includes conflict situations; Requires dealing with unpleasant, angry, or discourteous people; Requires being exact or highly accurate; Mistakes are not easily correctable and have serious consequences; Requires meeting strict deadlines; Requires work with external customers or the public; Includes responsibility for work outcomes and results; Requires working in a office/cubicle environment; Requires lifting/carrying up to 25 lbs. when transporting work equipment or materials
License, Certification, or Registration
- Registered Nurse with current Texas license
- High school diploma or equivalent
- Utilization review
- 2 years in a health care environment
- Preferred: Inpatient clinical
- Preferred: Durable medical equipment (DME) retrospective review
- Preferred: Coding
- Preferred: Medicare review
- Preferred: Inpatient, outpatient or home health review for utilization
- Preferred: Medical necessity decision making using InterQual and/or local and national coverage determination guidelines
- Active Learning, Active Listening, Critical Thinking, Learning Strategies, Monitoring, Reading Comprehension, Science, Mathematics, Speaking, Writing
- Coordination, Persuasion, Service Orientation, Social Perceptiveness, Instructing, Negotiation,
Complex Problem Solving Skills
- Operations Analysis, Quality Control Analysis, Troubleshooting
- Judgment and Decision Making
Resource Management Skills
Desktop Computer Skills
- Spreadsheets, Internet, Navigation, Word Processing, Databases
Basic Utilization Management , ICD-9 and CPT Coding, Law and Government, Mathematics, Clerical, Customer and Personal Service, English Language
TMF offers an excellent benefits package, including:
- Medical, dental, vision, life, accidental death and dismemberment, and short and long-term disability insurance
- Section 125 plan
- Flexible schedules
- Competitive salary
- License/credentials reimbursement
- Free covered parking
PLEASE VISIT OUR CAREER CENTER TO APPLY!
TMF Health Quality Institute is an equal opportunity employer.