Independent Dispute Resolution Entity Nurse; Remote

Description

The Independent Dispute Resolution Entity (IDRE) Nurse role supports the Independent Review Organization (IRO) in quality assurance efforts of commercial health non-appeal, internal appeal, state external appeal, and Federal PPACA appeal cases. All IDRE Nurses are responsible for conducting quality assurance checks including analyzing medical records, and prior denials, ensuring proper clinical specialty is utilized for reviews, and appropriate evidence-based literature is used in support of rationale.

Additionally, the IDRE Nurses ensure that details of the patient’s condition, physician orders, course of treatment, and well-supported rationale are present within the clinical reviewer’s final review. This job requires access to confidential and sensitive information, requiring ongoing discretion and secure information management.

• Comprehension of medical/surgical modalities and imaging techniques
• Ability to analyze clinical documentation, prior denials, and supporting documentation to ensure the quality of the clinical reviewer’s final review
• Audit and analyze patient records to ensure quality patient care and appropriateness of services
• Utilize pre-approved criteria/guidelines and plan language to validate medical necessity/appropriateness of treatment (e.g. Policy Plan Language, Milliman Care Guidelines, Inter Qual)
• Ability to understand and analyze plan language documentation
• Proper citation of evidence-based literature and requirements of clients
• Keeps current with regulation changes
• Perform a low to moderate amount of research on a case-by-case basis
• Conducts audits to ensure high-quality, professional reports that are free of grammar and spelling errors are delivered to the client
• Communicate with physician reviewers to address/correct errors or omissions and to investigate questionable claims
• Responsible for amending reports, as needed, with any additional clinical information provided
• Participates in an interdisciplinary health care team to achieve positive outcomes
• Ability to complete an average daily caseload of 15-20 cases once released from training
• Requires regular and consistent attendance
• Other duties as assigned

• Knowledge of Basic Anatomy
• Comprehension of medical/surgical modalities and imaging techniques
• Ability to analyze clinical documentation in relation to utilization reviews
• Ability to Interpret and apply appropriate guidelines to utilization reviews
• Ability to use logic and reasoning to determine and utilize appropriate evidence-based guidelines
• Ability to read, analyze, and interpret documents, reports, technical procedures, governmental regulations, and correspondence
• Ability to write routine reports and correspondence; and ability to present information in one-on-one, small group, and large group situations to management and staff
• Ability to apply proper grammar, spelling, punctuation, and formatting to typed material
• General Typing Skills at 45wpm
• Ability to use Microsoft products, Word, Excel, PowerPoint, Outlook
• Perform various computer functions including saving, copying, pasting, scrolling, etc
• High level of oral and written communication skills with a demonstrated ability to deliver excellent customer service
• Communicate professionally and effectively with physician reviewers, staff, and clients from all departments within and outside the Company.
• Demonstrated ability to work cross-functionally to solve complex problems and improve quality and service
• Must have a track record of producing work that is highly accurate, demonstrating attention to detail
• Build professional relationships that support the brand and its image
• Ability to multi-task and quickly adapt to a fast-paced environment
• Maintain a positive attitude and outstanding customer service while working closely internally with Nexus team members, panel physicians, and clients
• Strong organizational skills
• Attention to detail
• Proficiency in English with an aptitude for spelling and grammar
• Exemplary planning and time management skills
• Ability to multi-task, prioritize, and work in high pressure, deadline-driven environment
• Demonstrated ability to…