Responsible for analyzing patient records to determine legitimacy and necessity of medical services in compliance with government reimbursement policies. Review may be prior authorization, concurrent with service or post service. Review findings may be referred to a physician advisor for final determination.
ESSENTIAL JOB FUNCTIONS :
1. Review each selected record accurately and according to AFMC, state and federal policies and procedures.
2. Write effective and accurate review summaries and submit within appropriate time frame.
3. Refer all cases requiring additional review to the appropriate reviewer on a daily basis.
4. Maintain files for recording and reporting in accordance with established procedures.
5. Perform site surveys as required or directed.
6. Prepare monthly reports and/or statistics as directed.
7. Communicate effectively with internal and external clients.
9. Adhere to format, content and style guidelines, giving consideration to usability and ensuring accuracy, consistency, and quality.
10. Follow AFMC, state and federal protocols regarding data confidentiality/security and HIPAA compliance.
11. Additional duties as assigned.
Physical and Sensory Requirements (With or Without the Aid of Mechanical Devices) :
Mobility, reaching, bending, lifting, grasping, ability to read and write, ability to communicate with personnel, ability to remain calm under stress and ability to travel as needed. Must be able to lift and transport 25 pounds. Must be capable of performing the essential job functions of this job, with or without reasonable accommodations.
Required : Diploma or Associate’s degree in nursing, licensed as a Registered Nurse in the state of Arkansas
Desirable : Bachelor’s degree in nursing
Required : Three (3) years clinical nursing experience
Desirable : Quality Assurance / Utilization Review and/or coding experience, QIO experience
KNOWLEDGE, SKILLS AND ABILITIES :
Intermediate level computer skills (Excel, Word, Access, PowerPoint and Outlook)
Type 50 wpm
Exceptional skills in business English and spelling are required
Ability to maintain confidentiality
Strong oral and written communication skills
Excellent customer service
Ability to meet deadlines
Attention to detail
Knowledge of ICD Coding
Knowledge of HIT/EHR
Ability to work collaboratively and independently to achieve stated goals
Ability to relate professionally and positively with staff, business partners, customers, constituents, recipients and the public
Ability to multitask
Ability to prioritize
Strong organizational skills
Problem solving skills
Project management skills
Ability to read, interpret and apply laws, rules and regulations
Knowledge of quality improvement processes and techniques
Time management skills
Ability to travel, including overnight travel
Regular and punctual attendance
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