Position Description: HMS, Nurse Reviewer

The following description is quite detailed. Our intention is to provide insight into the opportunity so that you can make a well-informed choice.

Opportunity Snapshot

Enjoy optimal work-life balance with a regular schedule (no shift work) and you join an exciting new contract to conduct utilization review services for Massachusetts' Medicaid program.

In today's recessionary environment, this is truly a "best of both worlds" opportunity where you can keep your skills sharp within the clinically sophisticated environment of Permedion, a recognized leader in the assessment of healthcare services, and bask in the resources and stability of Health Management Services (HMS), our parent corporation, just ranked #3 on Fortune's 2009 FSB 100 list of America's fastest growing small public companies.

We have a number of Nurse Reviewer positions and depending on your background and skill sets you will be assigned to work within the following two departments:

Admissions Screening -- you will spend almost all of your time on the phone evaluating requests for admission approvals as you apply the appropriate InterQual review criteria to either approve services or refer requests to a physician. In particular, you will be mindful of certain over utilized procedures as well as cosmetic procedures and/or procedures that have not yet been clinically proven to be effective.
Pre-payment/Post-payment Review -- you will perform retrospective chart reviews per contract specifications while applying the appropriate InterQual criteria to approve services or refer requests to a physician.

For 35 years Permedion, an HMS company, has provided external medical peer reviews and independent health care review services for government agencies and large health care providers. Permedion is accredited by URAC in both Independent Review and Utilization Management. Founded in 1985, HMS offers one of the broadest portfolios of service to help government-sponsored healthcare plans recover billions of dollars and save billions more through cost avoidance. While others are cutting back, HMS is growing: our 2008 revenues of $184 million were up more than 20% over 2007, and and we've maintained that growth rate through the first half of 2009.

What You'll Bring to the Table

Active, unrestricted Massachusetts RN license.
5+ years of progressive clinical experience; the ideal candidate will have some utilization review, chart audit or quality assurance background.
Knowledge in and successful application of basic level health care data analysis and clinical review.
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.

Preferred, but not required:

Medicaid review background and knowledge of federal and state regulations.
Knowledge of billing and coding practices.

What's in It for You

Ground-floor impact -- you will be a pivotal member of this program and your input and decisions will impact the success and growth of this new 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 URAC accreditation requires 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.
Great work environment -- throughout Permedion we maintain a congenial environment with a collaborative approach to achieving results. As a member of the program launch team you'll help shape the culture in the Charlestown facility.
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. Permedion and HMS are 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

On July 15, 2009 Permedion won the Massachusetts Acute Hospital Utilization Management Program contract with the University of Massachusetts, the agent administering the state's Medicaid program. In addition to the 30 professionals coming on board in facilities in Charlestown, MA, the program will take advantage of support and resources from other areas of Permedion.

This is an individual contributor role, reporting to the Admission Screening Manager or Review Manager.

In general, your responsibilities (within the respective department you are assigned to) will include:

Admission Screening
Receiving and reviewing requests for approval of admissions via telephone, fax, or Web.
Collecting additional data as necessary to evaluate requests.
Applying appropriate clinical criteria (Interqual).
Utilizing clinical expertise to approve services or referring requests to a physician for review.
Overseeing referrals to and from physician reviews.
Formatting and editing approval and denial letters.
Assisting with mailing and faxing of letters in the absence of an Intake Coordinator.
Entering decisions directly into MMIS system.
Review
Performing retrospective chart review per contract specifications.
Collecting additional data as necessary to evaluate requests.
Applying appropriate clinical criteria (InterQual).
Utilizing clinical expertise to approve services or refer requests to a physician for review.
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 utilization review 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

Permedion 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.

With a unique combination of statistical and clinical expertise, Permedion works with government agencies, managed care organizations, and other payors to review, measure and improve health care quality. Our staff includes physicians, nurses, epidemiologists and data analysts, systems experts, and health administration experts. Our partners and customers include health plans, physician groups, government agencies, and professional associations.

Permedion is a wholly owned subsidiary of Health Management Systems, Inc. (HMS), providing clinical expertise to all HMS service lines. HMS is an industry leader in the coordination of program integrity and benefits services for government healthcare programs. Since 1985 HMS has focused exclusively on the healthcare industry and during that time we have 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. Our portfolio of services includes coordination of benefits for Medicaid-Medicare, third-party liability, and pharmacy services; overpayment recovery; provider audits; medical support enforcement; and more.

We are an equal opportunity employer. EOE M/F/D/V