CERIS, a division of CorVel Corporation, a certified Great Place to Work® Company, offers incremental value, experience, and a sincere dedication to our valued partners. Through our clinical expertise and cost containment solutions, we are committed to accuracy and transparency in healthcare payments. We are a stable and growing company with a strong, supportive culture along with plenty of career advancement opportunities. We embrace our core values of Accountability, Commitment, Excellence, Integrity and Teamwork (ACE-IT!).
CERIS Professional Review Nurse III
Location
United States
Posted
3 days ago
Salary
$62.3K - $93.1K / year
No structured requirement data.
Job Description
Role Description
The CERIS 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
This is a remote position.
Qualifications
- 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 is preferred
- Thorough knowledge of both C.P.T. and I.C.D.10 codes is 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
Requirements
- Identify the necessity of the review process and communicate any specific issues of concern to the claims examiner/client and/or direct reporting manager
- Collect supporting data and analyze information to make decisions regarding appropriateness of billing, delivery of care and treatment plans
- Completely document work and final conclusions in designated computer program
- Adhere to regular and consistent work attendance
- Comply with all safety rules and regulations during work hours in conjunction with the Injury and Illness Prevention Program (IIPP) and other requirements as outlined in the Employee Handbook
- Responsive to additional Professional Review job duties as assigned by management or determined by legislative changes and/or market changes
Benefits
- Medical (HDHP) w/Pharmacy
- Dental
- Vision
- Long Term Disability
- Health Savings Account
- Flexible Spending Account Options
- Life Insurance
- Accident Insurance
- Critical Illness Insurance
- Pre-paid Legal Insurance
- Parking and Transit FSA accounts
- 401K
- ROTH 401K
- Paid time off
Company Description
CERIS, a division of CorVel Corporation, a certified Great Place to Work® Company, offers incremental value, experience, and a sincere dedication to our valued partners. Through our clinical expertise and cost containment solutions, we are committed to accuracy and transparency in healthcare payments. We are a stable and growing company with a strong, supportive culture along with plenty of career advancement opportunities. We embrace our core values of Accountability, Commitment, Excellence, Integrity and Teamwork (ACE-IT!).
CorVel is an Equal Opportunity Employer, drug free workplace, and complies with ADA regulations as applicable.
Job Requirements
- 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 is preferred
- Thorough knowledge of both C.P.T. and I.C.D.10 codes is 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
- Identify the necessity of the review process and communicate any specific issues of concern to the claims examiner/client and/or direct reporting manager
- Collect supporting data and analyze information to make decisions regarding appropriateness of billing, delivery of care and treatment plans
- Completely document work and final conclusions in designated computer program
- Adhere to regular and consistent work attendance
- Comply with all safety rules and regulations during work hours in conjunction with the Injury and Illness Prevention Program (IIPP) and other requirements as outlined in the Employee Handbook
- Responsive to additional Professional Review job duties as assigned by management or determined by legislative changes and/or market changes
Benefits
- Medical (HDHP) w/Pharmacy
- Dental
- Vision
- Long Term Disability
- Health Savings Account
- Flexible Spending Account Options
- Life Insurance
- Accident Insurance
- Critical Illness Insurance
- Pre-paid Legal Insurance
- Parking and Transit FSA accounts
- 401K
- ROTH 401K
- Paid time off
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