Alvarez and Marsal Sr. Retrospective review nurse (Remote) in United States

The Remote Retrospective Review RN perform medical review provider claims, authorizations, and medical records to achieve resolution of authorization issues that result in claims denials or pended claims. Perform retrospective review for medical necessity appeals against medical review criteria to make benefit of determinations.

  • Utilize standard methodology and medical criteria sets to analyze and interpret member and/or provider claims, eligibility and quality data.
  • Perform retrospective readmission review of hospital and physician claims for admission appropriateness, coding, length of stay, and pricing
  • Identify potential process modification, changes, or automation to improve performance, quality, and efficiency.
  • Manage the review of medical claims, records, and authorizations for billing, coding and other compliance or reimbursement related issues
  • Implement and maintain production and quality standards for he medical review process Receive and respond to inquiries from Claims, Prior Authorization, and Concurrent Review staff.
  • Perform retrospective review of high dollar claims for benefit and pricing-determination.
  • Maintain departmental records, correspondence and files.
  • Work collaboratively with Finance to determine appropriateness of pricing
  • Assist with other clinical function of medical review

Main Duties & Responsibilities:

The Remote Retrospective Review Coordinator RN is responsible for ensuring proper utilization of health services by assessing the member’s needs and identifying solutions that promote quality and cost effective care. Perform utilization management, utilization review or concurrent review and Retrospective reviews leveraging Interqual guidelines and benefit determination.

  • Assess member’s needs
  • Identify solutions to problems and non-standard requests
  • Conducts UM review and discharge planning at the facility level (e.g., Acute, Long Term Acute Care (LTAC), Skilled Nursing Facility (SNF),
  • Follows and maintains compliance with regulatory agency requirements (NCQA)
  • Collaborate with staff, physicians, care/service coordinators, plan Medical Director, members and their families to coordinate and provide the level of care necessary to meet member’s health need
  • Ability to work remotely and be available for daily huddle calls via conference call and or WebEx sessions.

Voluntary Inclusion

It is Alvarez & Marsal’s policy to provide and promote equal opportunity in employment, compensation, and other terms and conditions of employment without discrimination because of race, color, sex, sexual orientation, family medical history or genetic information, political affiliation, military service, pregnancy, marital status, family status, religion, national origin, age or disability or any other non-merit based factor in accordance with all applicable laws and regulations.

Unsolicited Resumes from Third-Party Recruiters

Please note that as per A&M; policy, we do not accept unsolicited resumes from third-party recruiters unless such recruiters were engaged to provide candidates for a specified opening. Any employment agency, person or entity that submits an unsolicited resume does so with the understanding that A&M; will have the right to hire that applicant at its discretion without any fee owed to the submitting employment agency, person or entity.

  • Posted 8 Days Ago
  • Full time
  • 201700976