Position Description: Medical Review Nurse

Reporting to the Medical Review Manager (MRM), the Medical Review Nurse will provide professional assessment, planning, coordination, and implementation and reporting of complex clinical data to support the Medical Review Accuracy Contract for Provider Resources, Inc (PRI). The Medical Review Nurse will perform comprehensive medical record and claim reviews to make payment determinations based on applicable Medicare coverage policies and payment rules, coding guidelines, National and Local Coverage Determinations, and utilization/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
• 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
• Perform medical record and claims review in accordance with all State and Federal 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 policy verification
• 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
• Make clinical judgments based on clinical experience when applicable
• Understand and represent PRI?s mission, vision, and values to all internal and external customers
• Perform other duties as requested