SIU RN
Houston, TX, US
Position Type
Full-Time/Regular
Job Description
The SIU RN functions as part of the SIU, which is the designated unit responsible for the detection, prevention, investigation, education, correction and resolution of FWA. This individual is expected to apply clinical knowledge to assess the medical necessity, appropriateness of care and/or accuracy and appropriateness of billing/coding/scripts for professional, institutional and pharmaceutical healthcare benefits. This position also completes medical review summaries and reports and then coordinates findings with other Company clinicians to include Medical Directors and Clinical Pharmacists. The SIU RN provides clinical support to SIU team members and partners closely with coding and investigative staff on active FWA investigations. The SIU RN also conducts on-site audits with the investigative team as necessary to retrieve medical records and conduct provider interviews. This position also conducts patient, member and/or provider interviews to validate services billed were actually provided, with many of these specific to Explanation of Benefit grievances which are specific to FWA.
Responsibilities:
Provides case updates on progress of investigations and coordinates with SIU team members/management on recommendations and further actions and/or resolution
Develop and prepare internal clinical alerts for company-wide distribution with a focus on clinical policy improvement and/or gaps in case management, pre-authorization and formulary versus brand pharmaceuticals
Works cooperatively with other Plan departments including, but not limited to, Pharmacy, Utilization Management, Provider Relations, Claims, Medical Economics, Finance, Internal Audit, Process Integrity, Legal, and Sales/Marketing
Contacts members, pharmacies, providers and third parties via telephone interview and/or letter to validate claim submissions
Arranges and conducts meetings with providers, employees, business partners and where appropriate, representatives from regulatory agencies and law enforcement in conduct of investigations
Prepares summary and/or detailed reports on investigative findings for referral to state and federal agencies to include, but not limited to, the MEDIC, DOI, FBI, HHS-OIG, MFCU, and local law enforcement
Responsible for reviewing medical records/scripts and claims for accuracy of services related to clinical standards of practice and care, levels of care provided, correct coding and billing, quality indicators using InterQual criteria and medical necessity guidelines
Participates as an attendee for internal committees to present FWA topics/initiatives and attends external meetings as necessary
Assists in formulating questions for expert/peer review specific to FWA investigations
Responsible for maintaining confidentiality of all sensitive information
Provides annual or department specific FWA training to employees and delegated entities as required
Develops and maintains contacts/liaison with law enforcement, regulatory agencies, task force members, other SIU staff and other external contacts involved in fraud investigation, detection and prevention.
Sarbanes-Oxley Act requirements:
Has direct responsibility for compliance with the Sarbanes-Oxley Act in matters of financial and operational controls, and disclosure requirements as mandated by the act. This includes strict adherence to the company’s Business Conduct Statement and Code of Ethics. The emphasis will be on compliance with financial procedures and protocol, internal controls, and maintaining the highest level of workplace behavior.
Required Skills
Excellent oral and written communication skills, and strong analytical skills
Must have strong organizational/time management skills
Collaborative team player
Track record in building constituency consensus and fostering relationships with internal/external departments and agencies
Ability to support heavy workload and meet critical regulatory guidelines.
Required Experience
Experienced Required:
Previous experience in anti-FWA activities to include SIU or Program Integrity Units/Programs preferred
Minimum of three years experience in either an inpatient or outpatient setting
Minimum of two years experience working in an insurance Company with Managed Care or Government programs, preferably having Prescription Drug Plan (PDP), Medicare Advantage (MA), or Healthcare Management Organization (HMO).
Education/Certifications:
Current RN License active for past five years. TX licensure preferred.
Hold one or more designations as an Accredited Healthcare Fraud Investigator (AHFI), Certified Fraud Examiner (CFE), Certified Professional Code (CPC), Certified Professional Coder-Hospital (CPC-H), AHIMA Certified Coding Specialist (CCS), AHIMA Certified Coding Specialist-Physician Based (CCS-P) or a Certified Legal Nurse Consultant (CLNC) preferred
Travel Required:
Some Travel is required
Universal American Corp. is proud to be an equal opportunity/affirmative action employer. We are committed to attracting, retaining and maximizing the performance of a diverse and inclusive workforce.
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Company Name: Deluca & Weizenbaum Ltd.
Location: Providence, RI
Job Category: Healthcare; Other
Position Type: Full-Time, Employee
NURSE: Registered Nurse
Successful plaintiffs’ medical negligence litigation firm seeks experienced, in-house, full-time, Legal Nurse Consultant. Lasting career opportunity offering competitive salary. Please respond with letter of interest and CV to rachael@dwlaw.us.
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Nurse Paralegal / Legal Nurse Consultant
Location: Buffalo, NY, 14223
Several Full-time staff positions exist for a qualfied RN looking to make a change into the Legal arena and/or an experinced Nurse Paralegal / Legal Nurse Consultant (LNC).
Candidates must be an RN with a bachelor’s degree in Nursing. Candidate must have a variety of practical nursing experience with adults. Legal experience not necessary, but would be preferred.
Salary commensurante with exp – Range $45 – $60k
Apply Here!
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Medical Analyst
Litigation Management, Inc.
Client Name: Litigation Management, Inc.
Location: Mayfield Hts.
Salary: Salary not Determined
Job Type: Full-Time
Shift: 8.5 hour shift between the hours of 8:30 am – 6 pm
Job Description:
Litigation Management, Inc. provides comprehensive analyses of medical information for the defense of claims, individual lawsuits, mass torts or class actions where health, illness or injury is an issue. Our staff of medical, legal, and healthcare industry professionals deliver customized work products that distill large volumes of medical records into clear and concise analyses that are on-time every time. We are in looking for experienced nursing, medical, or other healthcare professionals with a variety of clinical, quality, or training expertise.
LMI provides in-depth training that prepares experienced healthcare professionals to review medical records, analyze the content, and prepare specialized reports for law firms and insurance companies in defense of an active or pending legal claim. The Medical Analyst contributes to the successful completion of product(s) designed to meet client needs and expectations. The Medical Analyst draws on medical knowledge/expertise to review medical and other plaintiff specific records and prepares an assessment of the information in a manner which will be of the most value to the client. The work involves a wide variety of claims
The Medical Analyst works on-site in Mayfield Heights, Ohio, Monday – Friday, 40 hours per week, 8.5 hours days, to be worked within core business hours of 8:00 a.m. and 6:00 p.m. as approved by manager.
GENERAL REQUIREMENTS:
-Strong clinical background in a variety of areas
-Knowledge of medical records, anatomy and disease processes/pathophysiology
-Clear, concise and professional verbal and written communication skills
-Demonstrated ability to use strong analytical , creative reasoning skills, and apply independent judgment when problem solving
-Strong interest in reading, writing and technology
-Experience with effectively managing multiple projects, assignments, and roles to meet deadlines
-Strong attention to detail with a focus on quality
-Proven flexibility to adjust to changing assignments and business needs
REQUIRED QUALIFICATIONS:
-Registered Nurse, RN/JD, Physician Assistant, or MD/DO
-Other clinical health professionals will be considered
-Five or more years in the clinical health care setting
PREFERRED QUALIFICATIONS:
-Bachelor prepared nurses.
-Certification as Legal Nurse Consultant.
-Background in Nurse Paralegal or Research Nurse.
-Advanced degree in Business, Law or Medical field.
COMPUTER REQUIREMENTS:
-Strong computer proficiency a must including keyboarding and using a mouse.
-Experience with PCs, Internet, and Microsoft Office Suite (Word, Excel, Outlook) required.
-Experience using a dual monitor is a plus.
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Title: Central Appeals Supervisor
Job Type: Manager/Supervisor, Manager/Administration, Manager/Administration, Director/Manager (Hospital/Medical Center), Supervisor/Manager (Retail), Admin/Mgr/Charge
Date: 7-22-2010
Location: Baltimore, MD
Description:
Your future is bright at CareFirst.
CareFirst BlueCross BlueShield is the largest health care insurer in the Mid-Atlantic region. Every day, we help people make decisions that will positively impact their lives today and into the future. Take your experience to the next level in a company that is financially strong and nationally respected as a Central Appeals Supervisor at our Baltimore campus in Canton Crossing.
This role is responsible for supervising Business Analysts and Operations Coordinators who support the Medical Review and Appeals activities for CareFirst BCBS members.
Responsibilities:
* Develops reporting and analysis standards and program criteria with established goals to ensure quality of the medical review and appeals programs provided by CareFirst BlueCross BlueShield and its subsidiaries.
* Ensures adequate reporting coverage and appropriate communication with internal and external customers.
* Oversees plans, schedules, and documentation of reports and SOP’s to ensure timely completing of reports and the meeting of business needs of the department.
* Evaluates performance of associates and places emphasis on professional development.
* Coordinates, analyzes, documents and responds to internal and external audit queries and formal audits to Medical Review and Appeals l including collaborative communication to responsible management of various departments, with direction and coordination of the reporting and analysis systems that will support these audit functions.
* Assists the Managers of Central Medical Review and Central Appeals and Analysis with the development, design, and implementation of new Central Medical Review and Appeals and Grievance programs and initiatives.
* Will be required to travel to the Union Center Plaza location in Washington, DC.
Qualifications:
* Must be Maryland RN licensed with a minimum of 10 years of medical-surgical experience and possess a degree in healthcare.
* At least 5 years in a Medical Review, Utilization Management, Central Appeals and Analysis or Care Management at CareFirst or other managed care entity.
* Exceptional professional communications skills are essential.
* MS Degree in a related health informatics field, or Certified Case Manager (CCM) or Legal Nurse Consultant Certified (LNCC) certification preferred.
Incumbent will demonstrate initiative and analytical prowess; work well independently and as a contributing member of a team; and demonstrate strong problem-solving, communication and organizational skills.
We offer excellent benefits and a competitive salary. Our Canton Crossing location is conveniently located in Baltimore and offers free parking. For complete job description and/or to apply online, please visit us at www.carefirst.com and search our jobs database by req. #003659.
EOE, M/F/D/V
CareFirst BlueCross BlueShield is an independent licensee of the Blue Cross and Blue Shield Association.
* Registered trademark of the Blue Cross and Blue Shield Association.
* Registered trademark of CareFirst of Maryland, Inc.
Apply Here!
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Prestigious Baltimore medical malpractice law firm seeks registered nurse with 2-5 years clinical and legal nurse consultant experience for full time in house position.