RCM is a premier single-source provider of business and technology solutions with a strong vertical focus offering an integrated suite of services through a global delivery platform.

RCM enables clients to realize the full value of their technology investments through the design, development and implementation of innovative solutions that fuel growth and profitability.

Our combination of strong technical expertise and extensive industry knowledge drives RCM's ability to bring effective and efficient solutions to the critical business challenges of our clients resulting in a powerful competitive advantage in existing markets, development of new markets and accelerated delivery of products and services.

Visit us online at www.rcmt.com for more information.

Retrospective Review and Claims Review Nurse Case Management (LPN/RN), Bronx, NY

Established and respected Managed Care Organization in the Bronx is looking for.......

 

Retrospective Review and Claims Review Nurse Case Management (LPN/RN), Bronx, NY

 

MUST HAVE recent and strong experience with ICD9 and CPT4 coding and retrospective review in a managed care setting!!

 

Assist in the management of utilization resources and perform clinical review for requested medical services per Medical Management policies and procedures to ensure the provision of quality health care services to members and the efficient utilization of resources.

ESSENTIAL FUNCTIONS:

• Performs prospective, concurrent and retrospective review of hospitalizations telephonically and/or on-site as appropriate.
  
• Monitors medical necessity of length of stay and quality of care of all hospitalized members.
  
• Performs prior authorization of elective procedures/services with medical necessity review as required.
  
• Assigns appropriate ICD-9 and CPT-4 codes to diagnoses and procedures for accurate claims payment and documents codes in essential authorization fields of the medical management system.
  
• Monitors medical necessity and length of service for outpatient and home care services.
  
• Maintains rapport with a variety of health care professionals including hospital UR department staff, discharge planners, social workers, health center liaisons, primary care physicians, attending physicians, specialty providers, outside vendors and various Affinity staff.
  
• Applies review criteria appropriately and in keeping with departmental policy and procedures.
  
• Flags cases with quality of care issues for QA.
  
• Participates in MM Case Rounds and MM departmental staff meetings.
  
• Identifies and refers cases to complex case management per departmental policy.
  
• Participates with the attending physicians, primary care physicians, social workers, and discharge planners in transitioning patients to the most appropriate level of care.

Job Requirements-

• Current NYS RN or LPN License. Certified Case Manager preferred. Certified Professional Coder preferred. Must be trained/experienced in Milliman Care Guideline Criteria.
  
• Minimum four (4) years experience in Discharge Planning, and/or Case Management, Utilization Management Review, Retrospective Review, ICD-9 and CPT-4 coding.
  
• Knowledgeable on Medicaid/Medicare Case Management review criterion.
  
• Hospital OB/GYN, Med Surg, ICU, ER, and or Home Care exp.
  
• Microsoft Office applications experience; Healthcare software applications experience, similar but not limited to Millliman Care Guidelines web software, DRG Assignment software, and other Care Management software packages.