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Medical Review Specialist

Medical Review Specialist
Company:

Infinit-O


Details of the offer

Basic FunctionThe Medical Review Specialist are in charged to do medical necessity reviews and provide clinical judgment/opinion based on policies and standards.
EducationBachelor’s or MS degree in Nursing, Medical Degree, or 5 years minimum of pertinent job experience
OPTIONAL:
ACM (Accredited Case Manager) Through AMCA (American Case Management Association)
CCM (Certified Case Manager) CCMC (Commission for Case Manager Certification)
Board certification in Nursing Case Management (RN-BC) through ANCC ( American Nurses Credentialing Center)
Specific Duties and ResponsibilitiesThe Medical Review Specialist will perform the functions outlined below:
Oversees the day to day peer review process from acceptance of cases for reviews, facilitating first level screening if applicable, preparation of case review documents, documentation of review results, production of reports and maintenance of the review records
Meet tight, changing deadlines in high volume
Collaborates with physician leadership regarding reviews for: Orthopedic (Ortho), Neurosurgery (Neuro), Pain Management (PM), Physical Medicine & Rehabilitation (PM&R), Surgery, etc. Ensures compliance to all standards and regulations involving medical staff peer review
Ensures compliance with the peer review process as outlined in the clients requirements
Secures all documents utilizing review protection. (Email and/or web portal submission)
Proactively reviews professional sources for changes in the review process, regulatory changes, and legal
Incorporates information from medical reports, radiology reports, physical therapy reports, chiropractic reports, and other sources into the review process
Ensures confidentiality with patient and physician information, PHI, and demonstrates understanding of HIPAA
Answers the phones and responds to needs professionally
Willingly takes on additional assignments as needed
Reports to work as scheduled, on time, sufficiently rested to perform the duties of the job
Takes initiative in keeping the Manager / Director fully informed on work related issue
As a member of the team, this individual will commit to actively pursuing improvements in quality and metrics and support quality initiatives, including continually looking for ways to improve the review process
QualificationsKnowledge in the following areas: Medicare and Medicaid regulations, Commercial Insurance Plans, Workman’s Compensation, Disability
Ability to define problems, collect data, establish facts, and draw valid conclusions
Advanced knowledge in the following areas: healthcare regulations, accreditation guidelines, and standards related to the peer review process
Must be Internet and computer literate – Proficient in PDF, word, excel, business class email – previous experience working in a portal environment is a plus
Must be able to write and speak professionally in English
Excellent analytical, critical thinking, and problem-solving skills
Ability to manage multiple priority projects simultaneously
Able to work flexible hours as needed
Able to work effectively and efficiently under tight deadlines, high volumes and multiple interruptions
Visit us at: Infinit-O | BPO Outsourcing Companies Philippines
Apply Now


Source: Jora

Job Function:

Requirements

Medical Review Specialist
Company:

Infinit-O


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