Professional Review Nurse

Description

The Professional Review Nurse provides analysis of medical services to determine appropriateness of charges on multiple types of medical bills and review of medical reports to determine appropriateness of medical care.  Clinical and/or technical expertise is utilized to address the provision of medical care and to identify inappropriate billing practices and errors inclusive of, but not limited to; duplicate billing, unbundling of charges, services not rendered, mathematical and data entry errors, undocumented services, reusable instrumentation, unused services and supplies, unrelated and/or separated charges, quantity and time increment discrepancies, inconsistencies with  diagnosis, treatment frequency and duration of care, DRG validation, service/treatment vs. scope of discipline, use of appropriate billing protocols, etc. 

KNOWLEDGE & SKILLS:

• Concise and effective verbal and written communication skills 
• Ability to interface with claims adjusters, attorneys, physicians and their representatives, advisors/clients, and co-workers
• Ability to effectively promote all Professional Review products with attorneys, claims examiners, customers and management
• Strong ability to effectively negotiate provider fees
• Must be proficient with Microsoft Office applications
• Knowledge of worker's compensation claims preferred

EDUCATION & EXPERIENCE:

• Must maintain current licensure as a Registered Nurse in the state of employment with a minimum of 4 years clinical experience
• A minimum of an Associate Degree in Nursing as well as have a thorough knowledge of both C.P.T. and I.C.D.9 codes preferred
• Medical bill auditing experience preferred
• Experience in the clinical areas of O.R., I.C.U., C.C.U., E.R., and orthopedics preferred
• Prospective, concurrent and retrospective utilization review experience preferred