Remote Registered Nurse - Medical Review Specialist

Avosys is a growing integrator of professional, technological and management solutions services. Founded in 1998, Avosys provides services nationwide to Federal, Commercial, Local and State clients. We recognize the foundation of our firm is our people and we continue to rise above our competition by hiring the best.

Avosys is seeking a Remote Registered Nurse - Medical Review Specialist to work remotely to review Medicare clains..

• Perform clinical reviews of Medicare Part A and Part B claims for Medical Review, Redeterminations/Appeals (Appeals), and Prior Authorization requests (collectively, the “Services”) in accordance with CMS (Centers for Medicare & Medicaid Services) requirements
• Complete a projected number of clinical review hours while meeting timeliness and accuracy standards and completing documentation of clinical decisions for remittance.
• Maintain work-life balance with guaranteed 8-hour shifts
• Maximize family time with no weekend, Holiday, or on-call requirements
• Take advantage of our competitive, comprehensive benefits package including medical, dental, vision, life, short-term disability, long-term disability & 401(k)

Clinical review of services

• Utilize the applicable Medicare policies (i.e., Local Coverage Determinations, National Coverage Determinations, Internet-Only Manual (IOM) citations, inpatient tools, etc.) to ensure the services comply with all Medicare regulations and documentation requirements
• Review documentation for medical necessity per guidelines outlined in the Social Security Act 1862(a)(1)
• Review medical record documentation within CMS timeliness parameters (i.e., 20 days from receipt of the medical record for pre-payment reviews and 50 days from receipt of the medical record for post payment reviews)
• Ensure that all documentation includes a valid signature consistent with the signature requirements

Documentation of rationale for processing decisions

• Lead and Alternate Lead will participate in all monthly departmental training and meetings, and all Staff will participate as requested
• Conduct telephone development for missing or additional records for easily curable errors
• Companies will review the three-claim sample for accuracy of claim decision and will make and return decisions to the MRS within 24 hours or less
• Complete the documentation of the reason for payment, reduction, or denial of service for all claims on an electronic decision template to be provided by Companies. This rationale must be in sentence format so that it may be inserted directly into the response to the provider, must be clear and well-written, and contain sufficient information to educate the providers on how the review decision was made
• Provide a claim sample of three (3) claims to Companies via established protocols and timeliness parameters (i.e., 18 days from receipt of the medical record for pre-payment reviews and 48 days from receipt of the medical record for post payment reviews) for quality review prior to finalization of documentation of reason for payment, reduction, or denial of service to ensure accuracy of claim decision making
• Minimum of two (2) years’ clinical experience
• Excellent written and oral communication skills
• Return documented decision electronically to Companies via established protocols and timeliness parameters (i.e., 20 days from receipt of the medical record for pre-payment reviews and 50 days from receipt of the medical record for payment reviews)
• Complete referrals to Companies’ provider outreach and education (“POE”) area in provider tracking system for cases that have a moderate or major error rate
• Active and current Registered Nurse license
• Demonstrated experience with evaluating medical and health care delivery issues
• Respond to provider inquiries related to case and/or claims throughout the course (i.e. in 24 hours or less) of review
• If fraud activity is suspected, immediately complete initial referral packet for external entity referral and return the packet to the Companies
• Submit all cases for review and approval for quality and closure of cases
• Document all case activity in Companies’ provider tracking system on the day the activity occurs
• Complete the review results letter in the Companies’ letter writing system within 35 days from receipt of the medical record for pre-payment reviews and no later than 60 days from receipt of the medical record for post payment reviews
• Complete one-on-one provider education (i.e., webinar, conference call, etc.) within 30 days of sending out review results letter
• Notate date of receipt of additional documentation received in the Companies’ provider tracking system
• Strong computer skills to include Microsoft Office proficiency
• Upon request by Companies, initiate or participate in provider teaching activities, creating written teaching material, providing one-on-one education or education to a group as a result of an MR review
• If additional clinical guidance is required, complete the Contractor Medical Director (“CMD”) assistance form, track response, and update review accordingly

Industry Defense

US Citizenship Required Yes

Background Check Required

Current Clearance Level Required None

Telework Yes

Travel No

Equal Opportunity Employer/Veterans/Disabled

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, gender identity, national origin, or protected veteran status and will not be discriminated against on the basis of disability. If you are an individual with a disability and require a reasonable accommodation to complete any part of the application process, or are limited in the ability or unable to access or use this on-line application process and need an alternative method for applying, you may contact (210) 888-0775 or [email protected] for assistance.

Provide support for web-based Collaborative Services (SharePoint, Samepage, G Suite, ClickUp, Zoho Workspace or similar).

• 4
• Coordinate with higher headquarters to implement upgrades and migration actions for existing data as required.
• Provide both group and individual training to end users and program managers as directed.
• 3
• Associate degree in Information Technology, Engineering, or related field.
• Provide a Status Report to customer on request that addresses work progress during the reporting month and shall address issues of concerns in this report.
• Ensure the appropriate web-based collaborative tool is available, current and operational to support customer requirements.
• 2
• Provide all required application design and development for new organizational initiatives including training to personnel.
• Years of experience in supporting Cybersecurity IT projects
• Excellent written, communication and presentation skills.
• Coordinate with local and geographically separated units (GSUs) as required to make available access to all tools and services in the collaborative environment(s).
• Ensure standardized branding for all organization sites at all levels.
• 2
• Research and evaluate new web-based collaborative tools and provide recommendations to customers for use based on mission requirements.
• Responsible for creating training content to be reviewed by the customer prior to dissemination using VTC capability provided by customer to conduct training.
• Years of experience in supporting, administering, managing content management platform such as Sharepoint
• Provide most effective method of providing training to end-users and program managers in the field upon request.
• Years of experience in providing technical training
• Responsible for creating or deleting permissions for user accounts as directed and coordinate with unit collaborative tools POCs to identify any special permissions or security group needs.
• Years of experience in design, development and implementation of custom collaboration websites (Sharepoint preferred)

Clearance Active Top Secret

Travel None

• Complete a projected number of clinical review hours while meeting timeliness and accuracy standards and completing documentation of clinical decisions for remittance.
• Perform clinical reviews of Medicare Part A and Part B claims for Medical Review, Redeterminations/Appeals (Appeals), and Prior Authorization requests (collectively, the “Services”) in accordance with CMS (Centers for Medicare & Medicaid Services) requirements

Clinical review of services

• Utilize the applicable Medicare policies (i.e., Local Coverage Determinations, National Coverage Determinations, Internet-Only Manual (IOM) citations, inpatient tools, etc.) to ensure the services comply with all Medicare regulations and documentation requirements
• Review documentation for medical necessity per guidelines outlined in the Social Security Act 1862(a)(1)
• Ensure that all documentation includes a valid signature consistent with the signature requirements
• Review medical record documentation within CMS timeliness parameters (i.e., 20 days from receipt of the medical record for pre-payment reviews and 50 days from receipt of the medical record for post payment reviews)

Documentation of rationale for processing decisions

• Respond to provider inquiries related to case and/or claims throughout the course (i.e. in 24 hours or less) of review
• Companies will review the three-claim sample for accuracy of claim decision and will make and return decisions to the MRS within 24 hours or less
• Provide a claim sample of three (3) claims to Companies via established protocols and timeliness parameters (i.e., 18 days from receipt of the medical record for pre-payment reviews and 48 days from receipt of the medical record for post payment reviews) for quality review prior to finalization of documentation of reason for payment, reduction, or denial of service to ensure accuracy of claim decision making
• Conduct telephone development for missing or additional records for easily curable errors
• 10912
• Complete the documentation of the reason for payment, reduction, or denial of service for all claims on an electronic decision template to be provided by Companies. This rationale must be in sentence format so that it may be inserted directly into the response to the provider, must be clear and well-written, and contain sufficient information to educate the providers on how the review decision was made
• If additional clinical guidance is required, complete the Contractor Medical Director (“CMD”) assistance form, track response, and update review accordingly
• Document all case activity in Companies’ provider tracking system on the day the activity occurs
• Return documented decision electronically to Companies via established protocols and timeliness parameters (i.e., 20 days from receipt of the medical record for pre-payment reviews and 50 days from receipt of the medical record for payment reviews)
• Complete the review results letter in the Companies’ letter writing system within 35 days from receipt of the medical record for pre-payment reviews and no later than 60 days from receipt of the medical record for post payment reviews
• Complete one-on-one provider education (i.e., webinar, conference call, etc.) within 30 days of sending out review results letter
• Notate date of receipt of additional documentation received in the Companies’ provider tracking system