REMOTE Registered Nurse - Medical Review Specialist-Bexar County, Texas

Job Title

Bexar County 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.

• Maximize family time with no weekend, holiday, or on‑call requirements
• Maintain work‑life balance with guaranteed 8‑hour shifts
• Competitive comprehensive benefits package including medical, dental, vision, life, short‑term disability, long‑term disability, and 401(k)

• Perform clinical reviews of Medicare Part A and Part B claims for Medical Review, Redeterminations / Appeals, and Prior Authorization requests in accordance with CMS requirements.
• Complete a projected number of clinical review hours while meeting timeliness and accuracy standards and documenting clinical decisions for remittance.
• Clinical review of services:
  • 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).
  • Utilize applicable Medicare policies (e.g., Local Coverage Determinations, National Coverage Determinations, Internet‑Only Manual citations, inpatient tools) to ensure compliance with all Medicare regulations and documentation requirements.
  • Review documentation for medical necessity per guidelines outlined in the Social Security Act 1862(a)(1).
  • Ensure all documentation includes a valid signature consistent with signature requirements.
  • Document rationale for processing decisions.
  • Provide a claim sample of three (3) claims to Companies via established protocols and timeliness parameters (18 days for pre‑payment reviews and 48 days for post‑payment reviews) for quality review prior to finalization of documentation of reason for payment, reduction, or denial of service.
  • 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 documentation of the reason for payment, reduction, or denial of service for all claims on an electronic decision template provided by Companies. This rationale must be in sentence format so 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.
  • Return documented decision electronically to Companies via established protocols and timeliness parameters (20 days for pre‑payment reviews and 50 days for post‑payment reviews).
• Complete 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 for post‑payment reviews.
• Document all case activity in Companies' provider tracking system on the day the activity occurs.
• Complete one‑on‑one provider education (e.g., webinar, conference call) within 30 days of sending out review results letter.
• Respond to provider inquiries related to case and/or claims throughout the course (within 24 hours or less) of review.
• If additional clinical guidance is required, complete the Contractor Medical Director (CMD) assistance form, track response, and update review accordingly.
• Conduct telephone development for missing or additional records for easily curable errors.
• Notate date of receipt of additional documentation in the Companies' provider tracking system.
• 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 fraud activity is suspected, immediately complete initial referral packet for external entity referral and return the packet to the Companies.
• Complete referrals to Companies' provider outreach and education (POE) area in provider tracking system for cases that have a moderate or major error rate.
• Lead and Alternate Lead will…