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.

Major Duties and Responsibilities:

•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, InterQual)

•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

Requirements

Knowledge and Abilities Requirements:

•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 problem solve complex, multifaceted, situations

•Ability to engage easily in abstract thought

•Strong organizational and task prioritization skills

Education/Credentials:

•RN with 1- 3 years of experience in a Managed Care setting

•Proficient computer skills: able to navigate through multiple software systems including, but not limited to, Microsoft Word, Excel, and Outlook

Driving Essential: No

Position Demands:

This position requires sitting, bending, and stooping for up to 8 hours per day in an office setting. Ability to lift and move objects weighing up to 20 lbs. Ability to learn technical material. The person in this position occasionally needs to move about inside the office to access filing cabinets, office machinery, etc. Must be able to operate a computer and other office productivity machinery such as a calculator, copy machine, printer, etc. The person in this position frequently communicates with guests, team members, and vendors and must be able to exchange accurate information.

Equal Employment Opportunity:

ProPeer is a veteran-owned Company and provides Equal Employment Opportunities (EEO) to all Team Members and applicants for employment without regard to race, color, religion, sex, sexual orientation, gender (including gender identity), pregnancy, childbirth, or a medical condition related to pregnancy or childbirth, national origin, age, disability, genetic information, status as a covered veteran in accordance with applicable federal, state, and local laws, or any other characteristic or class protected by law and is committed to providing equal employment opportunities. The company complies with applicable state and local laws governing non-discrimination in employment. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, promotion, discharge, pay, fringe benefits, membership, job training, classification, and other aspects of employment. Team Members who believe they are the victims of

discrimination should immediately report the concern to their Supervisor and Human Resources Department. Discrimination and harassment will not be tolerated.

We are committed to creating an inclusive environment for all Team Members and applicants. We value the unique skills and experiences that veterans bring to our team and encourage veterans to apply.

Disclaimer:

The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of our personnel. All team members may be required to perform duties outside of their normal responsibilities from time to time, as needed.