Medical Claims Review Manager jobs in Jacksonville, FL

Position Description: Medical Review Nurse (MRN)

Reporting to the Medical Review Manager, the Medical Review Nurse (MRN) will provide professional assessment, planning, coordination, implementation and reporting of complex clinical data and support the medical review operations of Provider Resources, Inc (PRI). The MRN position will perform comprehensive medical record and claim reviews from the Medicare fee-for-service program to make utilization and quality of care determinations based on applicable Medicare coverage policies, coding rules and guide lines, evidence-based standards of care and utilization and practice guidelines.

Responsibilities:

• Understand and represent PRI?'s mission, vision, and values to all internal and external customers
• Engage clients in appropriate communication that manages client expectations and builds a collaborative relationship with the client
• Provide first call resolution for internal and external users requiring assistance with issues and problems including any additional follow up that may be required
• Interact with project team members in order to successfully fulfill contract obligations with the highest quality and in a timely manner meeting PRI?'s ISO requirements
• Instills integrity throughout the organization via active participation in ISO requirements including but not limited to timely submission of Corrective Action Plans for all matters in which either PRI?'s standards and/or corporate contract standards have not been met. Communicating outcomes to team members to ensure a positive, open, environment which mitigates risk and achieves a culture of Continuous Quality Improvement

• Perform medical record and claims review in accordance with all State, Federal and/or commercially mandated regulations
• Maintain compliance with all regulation changes as they impact medical and utilization review practices
• Analyze patient records and participate in interdisciplinary collaboration with PRI staff and all recognized teaming partners and/or subcontractors
• Document all review information into the appropriate Medical Review form, report and/or system. Communicate these report results to the appropriate supervisor
• Utilize electronic health information imaging
• Utilize Internet and Intranet resources for applicable research, e.g., evidence-based standards of care guidelines, quality measures, etc.
• Utilize Mainframe shared system access to the Centers for Medicare & Medicaid Services? (CMS), Common Working File (CWF) to verify claims data information by query and search activities
• Engage clients in appropriate communication that manages client expectations and builds a collaborative relationship with the client
• Interact with government and private sector clients, partners, and PRI staff in a professional and accountable manner, and as a representative of PRI
• Contribute to business development efforts for new sales and marketing to promote the business, including responses to requests for quotes, sources sought, proposals, and/or presentations as requested
• Make clinical judgments based on evidence-based standards of care, review criteria and nursing practice guidelines when applicable
• Understand and represent PRI?s mission, vision, and values to all internal and external customers
• Perform other duties as requested