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Nurse Reviewer
NJ - Trenton
Opportunity Snapshot
As a Nurse Reviewer, you will have the opportunity fight fraud, waste and abuse in Medicaid spending projected to double in ten years. We are looking for a team of both field and in office Nurse Reviewers. The in office Nurse Reviewers will work out of our Trenton office, performing clinical reviews of medical records; screening for correct coding and medical necessity for admissions and services paid by the Medicaid Agency. To be a good fit for this opportunity you will have an active, unrestricted RN license, a solid clinical background and demonstrated knowledge of Medicaid/Medicare claims and reimbursement requirements. Quick question for you - click here
We need someone that has the finesse to conduct provider entrance and exit conferences.
This position offers you the opportunity not only to play a key role as part of the Medicaid Audit department, but also to join a thriving, fast growing national company. You will enjoy the resources and stability of Health Management Services (HMS), just ranked #3 on Fortune's 2009 FSB 100 list of America's fastest growing small public companies.
What You'll Bring to the Table
- Active, unrestricted New Jersey RN license.
- 5 years of progressive clinical experience; the ideal candidate will have some medical review, chart audit, acute care or quality assurance background.
- Knowledge of Medicaid/Medicare claims and reimbursement requirements.
- Excellent interpersonal and communication skills, both written and oral.
- The flexibility to multitask and address diverse case types.
- Solid computer proficiency within an MS Office suite environment, including Word and Excel.
- Ability to travel to and in New Jersey hospitals up to 25% Quick question for you - click here.
Preferred, but not required:
- Familiarity with billing, RA's and EOB's and knowledge of federal and state regulations.
- Knowledge of clinical criteria (Milliman or InterQual).
- Knowledge of billing and coding practices.
What's in It for You
- Pivotal impact -- you will be a pivotal member of this program and your input and decisions will impact the success and growth of our contract.
- Career advancement -- we're hiring now with an eye on the future, looking for impact players who can grow with us. You will be well positioned to transition into other growth opportunities, depending on your ambition and aptitude.
- Clinical sophistication through continuous improvement -- our accreditations require that we maintain continuous organizational improvement processes, and we never stop learning and growing. This spirit has enabled us to achieve industry recognition for our expertise. For example, we are designated by the Centers for Medicare and Medicaid Services (CMS) as one of eight Qualified Independent Contractors (QIC) in the US, meaning CMS acknowledges that we have the expertise and capabilities to perform appeals of Medicare claims between the carrier and Administrative Law Judge levels.
- Rapid growth in spite of down economy -- Medicaid and Medicare budgets are growing (CMS predicts current Medicare/Medicaid spending levels to double by 2015) and, with billions of dollars at stake, there is a strong emphasis among policy leaders (and the voting public) on cost containment and payment accuracy. HMS is taking advantage of this climate to drive solid growth. In addition to posting double-digit growth year over year since 2001, HMS is successfully expanding into new markets, including federal healthcare and managed care.
- Excellent compensation -- in addition to a competitive salary, we offer a comprehensive benefits package that includes all you would expect plus a few pleasant surprises, such as a 401(k) plan with generous employer match, flexible spending plans, and much more.
More About Your Role
In general, your responsibilities will include:
- Conducting utilization and quality of care reviews.
- Performing Diagnosis Related Group (DRG) validations of inpatient hospital medical services provided and billed for Medicaid fee-for-service beneficiaries.
- Collecting additional data as necessary to evaluate requests.
- Applying appropriate clinical criteria.
- Utilizing clinical expertise to approve services based on medical necessity or referring requests to a physician or coder for further review.
- Researching relevant State specific billing and reimbursement regulations.
- Providing support to internal staff with respect to Medicaid related issues.
- Conducting claims research using the appropriate systems.
- Performing retrospective chart review per contract specifications.
- Participating in and contributing to the quality management system.
- Preparing letters to summarize retrospective review activity.
- Evaluating, identifying and reporting on quality of care issues.
Keys to Success
To flourish in this environment, you will of course showcase your clinical competencies within medical reviews and also showcase solid due diligence and judgment skills as you thoroughly evaluate a variety of cases and deliver timely decisions. You will also be fully vested in the success of this new contract as you leverage your experience and recommend your own ideas for improvements. And last but not least, you will remain open to learning new technologies, processes and skills.
If this sounds like the right mix of challenge and opportunity for you, and you meet the minimum qualifications, we want to hear from you!
Who We Are
Health Management Systems (HMS) has always been focused exclusively on the healthcare industry. In 1985, we began providing third party liability identification and recovery services to our first Medicaid agency client. Since then, we've partnered with more than 45 Medicaid agencies, other state health programs, and more than 50 government-sponsored healthcare plans to help them recover billions of dollars and save billions more through cost avoidance.
HMS provides external medical peer reviews and independent health care review services for government agencies and large health care providers, helping them control escalating health care costs while providing appropriate medical care. Our three primary areas of service are health care quality measurement and improvement, data analysis and management, and independent medical review.
Opportunity Snapshot
As a Nurse Reviewer, you will have the opportunity fight fraud, waste and abuse in Medicaid spending projected to double in ten years. We are looking for a team of both field and in office Nurse Reviewers. The in office Nurse Reviewers will work out of our Trenton office, performing clinical reviews of medical records; screening for correct coding and medical necessity for admissions and services paid by the Medicaid Agency. To be a good fit for this opportunity you will have an active, unrestricted RN license, a solid clinical background and demonstrated knowledge of Medicaid/Medicare claims and reimbursement requirements. Quick question for you - click here We need someone that has the finesse to conduct provider entrance and exit conferences.
This position offers you the opportunity not only to play a key role as part of the Medicaid Audit department, but also to join a thriving, fast growing national company. You will enjoy the resources and stability of Health Management Services (HMS), just ranked #3 on Fortune's 2009 FSB 100 list of America's fastest growing small public companies.
What You'll Bring to the Table
- Active, unrestricted New Jersey RN license.
- 5 years of progressive clinical experience; the ideal candidate will have some medical review, chart audit, acute care or quality assurance background.
- Knowledge of Medicaid/Medicare claims and reimbursement requirements.
- Excellent interpersonal and communication skills, both written and oral.
- The flexibility to multitask and address diverse case types.
- Solid computer proficiency within an MS Office suite environment, including Word and Excel.
- Ability to travel to and in New Jersey hospitals up to 25% Quick question for you - click here.
Preferred, but not required:
- Familiarity with billing, RA's and EOB's and knowledge of federal and state regulations.
- Knowledge of clinical criteria (Milliman or InterQual).
- Knowledge of billing and coding practices.
What's in It for You
- Pivotal impact -- you will be a pivotal member of this program and your input and decisions will impact the success and growth of our contract.
- Career advancement -- we're hiring now with an eye on the future, looking for impact players who can grow with us. You will be well positioned to transition into other growth opportunities, depending on your ambition and aptitude.
- Clinical sophistication through continuous improvement -- our accreditations require that we maintain continuous organizational improvement processes, and we never stop learning and growing. This spirit has enabled us to achieve industry recognition for our expertise. For example, we are designated by the Centers for Medicare and Medicaid Services (CMS) as one of eight Qualified Independent Contractors (QIC) in the US, meaning CMS acknowledges that we have the expertise and capabilities to perform appeals of Medicare claims between the carrier and Administrative Law Judge levels.
- Rapid growth in spite of down economy -- Medicaid and Medicare budgets are growing (CMS predicts current Medicare/Medicaid spending levels to double by 2015) and, with billions of dollars at stake, there is a strong emphasis among policy leaders (and the voting public) on cost containment and payment accuracy. HMS is taking advantage of this climate to drive solid growth. In addition to posting double-digit growth year over year since 2001, HMS is successfully expanding into new markets, including federal healthcare and managed care.
- Excellent compensation -- in addition to a competitive salary, we offer a comprehensive benefits package that includes all you would expect plus a few pleasant surprises, such as a 401(k) plan with generous employer match, flexible spending plans, and much more.
More About Your Role
In general, your responsibilities will include:
- Conducting utilization and quality of care reviews.
- Performing Diagnosis Related Group (DRG) validations of inpatient hospital medical services provided and billed for Medicaid fee-for-service beneficiaries.
- Collecting additional data as necessary to evaluate requests.
- Applying appropriate clinical criteria.
- Utilizing clinical expertise to approve services based on medical necessity or referring requests to a physician or coder for further review.
- Researching relevant State specific billing and reimbursement regulations.
- Providing support to internal staff with respect to Medicaid related issues.
- Conducting claims research using the appropriate systems.
- Performing retrospective chart review per contract specifications.
- Participating in and contributing to the quality management system.
- Preparing letters to summarize retrospective review activity.
- Evaluating, identifying and reporting on quality of care issues.
Keys to Success
To flourish in this environment, you will of course showcase your clinical competencies within medical reviews and also showcase solid due diligence and judgment skills as you thoroughly evaluate a variety of cases and deliver timely decisions. You will also be fully vested in the success of this new contract as you leverage your experience and recommend your own ideas for improvements. And last but not least, you will remain open to learning new technologies, processes and skills.
If this sounds like the right mix of challenge and opportunity for you, and you meet the minimum qualifications, we want to hear from you!
Who We Are
Health Management Systems (HMS) has always been focused exclusively on the healthcare industry. In 1985, we began providing third party liability identification and recovery services to our first Medicaid agency client. Since then, we've partnered with more than 45 Medicaid agencies, other state health programs, and more than 50 government-sponsored healthcare plans to help them recover billions of dollars and save billions more through cost avoidance.
HMS provides external medical peer reviews and independent health care review services for government agencies and large health care providers, helping them control escalating health care costs while providing appropriate medical care. Our three primary areas of service are health care quality measurement and improvement, data analysis and management, and independent medical review.
