Nurse Educator/Review Coordinator

Description:

The Nurse Educator/Review Coordinator’s primary role is to facilitate provider education related to the claim reviews performed under Task Order 3 for the BFCC-QIO contract. The education provided will be dependent on the outcome of the reviews and may involve the application of Medicare policy, ICD-10-CM/PCS coding rules, DRG assignment, medical necessity, or other related claim review topics. The education may be provided to a single facility related to facility findings, or it may be at a more general level directed at a wider audience and encompass a wider variety of review findings. The ultimate goal of the education is to work toward decreasing Medicare’s paid claims error rate.

Requirements:

At Commence, we’re the start of a new age of data-centric transformation, elevating health outcomes and powering better, more efficient process to program and patient health. We combine quality data-driven solutions that fuel answers, technology that advances performance, and clinical expertise that builds trust to create a more efficient path to quality care.

With human-centered, healthcare-relevant, and value-based solutions, we create new possibilities with data. We provide proof beyond the concept and performance beyond the scope with a focus on efficiencies that transform the lives of those we serve. With a culture driven by purpose, straightforward communication and clinical domain expertise, Commence cuts straight to better care.

• Collaborate with staff, management, and the Medical Director to identify billing issues that could improve with provider education.
• Provide recommendations related to problem identification and proposed resolutions.
• Stay current on the latest evidence for new practices and quality indicators through learning activities, in-services, and information sharing.
• Uphold policies, procedures, and standards.
• Assist management with assessing staff competencies and needs for training.
• Assist management with the inter-rater reliability or other QA processes.
• Facilitate education sessions with providers on CMS-required medical record documentation for claim reviews.
• Facilitate the construction of final claim review provider letters.
• Promote activities to improve provider compliance.
• Serve as a liaison between the provider and the QIO.
• Perform desktop medical review.
• Interpret and apply review criteria as applicable to specific positions.
• Communicate with and support physician reviewers by summarizing case facts, preparing case questions, and assisting with resolving issues requiring physician input.
• Provide for the dissemination of current information necessary for the successful implementation of contract expectations.
• Provide feedback to Managers to assist with evaluation of staff.
• Maintain records/data related to job activities and duties.
• Protect the confidentiality of patient information through compliance with the Health Insurance Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health Act (HITECH).

Essential Knowledge:

Individuals must be detail-oriented and clinically knowledgeable in the area in which provider education will be provided.

Essential Education:

Graduation from an accredited school of nursing and current licensure as Registered Nurse (RN) or accredited as a Health Information Management professional (RHIA, RHIT, CCS) with requisite coding experience, skills, and knowledge. Individuals with a degree in a healthcare-related field who possess professional clinical backgrounds with Medicare QIO experience with claim reviews or in performing medical reviews in support of MAC or RAC appeals, pre- and post-pay claims reviews, and utilization reviews preferred.

Essential Skills:

• Ability to organize and coordinate multiple simultaneous tasks in a team environment
• Ability to follow complex written and oral instructions
• Ability to collect data, distinguish relevant material, and exercise sound judgment
• Ability to problem solve and maintain objectivity
• Must have strong computer keyboarding skills and be able to write clearly using the English language
• Ability to work independently with minimal supervision

Organizational "Fit" Considerations:

This is a remote work position, and the individual must be flexible and proactive in covering and overseeing services provided by the job function. This may require extended hours of work during the week, weekends, and on holidays, or on demand in order to maintain contract metrics.

Commence.AI is committed to providing equal employment opportunities to all applicants, including individuals with disabilities. If you require a reasonable accommodation to participate in the application process due to a disability, please contact Human Resources at (757) 306-4920 or hr@commence.ai. Please note that unless you are requesting accommodation, all applications must be submitted through our online application system.