SCOPE OF POSITION:
Responsible for analyzing patient records to determine legitimacy and necessity of medical services in compliance with government reimbursement policies. Review may be prior authorization, concurrent with service or post service. Review findings may be referred to a physician advisor for final determination.
ESSENTIAL JOB FUNCTIONS:
- Review each selected record accurately and according to AFMC, state and federal policies and procedures.
- Function as a resource for non-clinical staff by providing oversight and follow-up for clinical related questions or issues
- Write effective and accurate review summaries and submit within appropriate time frame.
- Refer all cases that do not meet established medical necessity criteria for approval to a peer clinical reviewer on a daily basis.
- Maintain files for recording and reporting in accordance with established procedures.
- Perform site surveys as required or directed if relevant to your department. Must be able to travel within the State as needed to accomplish required site visits if relevant to your department.
- Prepare monthly reports and/or statistics as directed.
- Communicate effectively with internal and external clients. Upon request, verbally informs patients, facility personnel, the attending physician and other ordering providers, and health professionals of specific utilization management requirements and procedures
- Seek direction from Review Manager, Clinical Director, Associate Medical Director, or VP Chief Medical Officer for any clinical related questions or issues during the review process.
- Daily quotas may be added to meet contract deliverables as needed.
- Adhere to format, content and style guidelines, giving consideration to usability and ensuring accuracy, consistency, and quality.
- Follow AFMC, state and federal protocols regarding data confidentiality/security and HIPAA compliance.
- Additional duties as assigned.
PHYSICAL AND SENSORY REQUIREMENTS (WITH OR WITHOUT THE AID OF MECHANICAL DEVICES):
Mobility, reaching, bending, lifting, grasping, ability to read and write, ability to communicate with personnel, ability to remain calm under stress and ability to travel as needed. Must be able to lift and transport 25 pounds. Must be capable of performing the essential job functions of this job, with or without reasonable accommodations.
KNOWLEDGE, SKILLS AND ABILITIES:
- Intermediate level computer skills (Excel, Word, Access, PowerPoint and Outlook).
- Type 50 wpm.
- Exceptional skills in business English and spelling are required.
- Ability to maintain confidentiality.
- Strong oral and written communication skills.
- Customer service.
- Ability to meet deadlines.
- Attention to detail.
- Knowledge of ICD 9/ICD 10 Coding.
- Knowledge of HIT/EHR.
- Medical terminology.
- Ability to work collaboratively and independently to achieve stated goals.
- Ability to relate professionally and positively with staff, business partners, customers, constituents, recipients and the public.
- Ability to multitask.
- Ability to prioritize.
- Strong organizational skills.
- Problem solving skills.
- Project management skills.
- Ability to read, interpret and apply laws, rules and regulations.
- Knowledge of quality improvement processes and techniques.
- Time management skills.
Required: Diploma or Associate’s degree in nursing, licensed as a Registered Nurse in the state of Arkansas without restrictions.
Desirable: Bachelor’s degree in nursing.
Required: Three (3) years clinical nursing experience.
Desirable: Quality Assurance / Utilization Review and/or coding experience, QIO experience.
Equal Opportunity Employer/Veterans/Disabled EEO IS THE LAW
AFMC, Inc. is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, or protected veteran status and will not be discriminated against on the basis of disability or any other status protected by federal, state and/or local law. AFMC invites any employee and/or applicant to review the Company’s Affirmative Action Plan. This plan is available for inspection upon request, which may be made in person or by telephone (501) 212-8798, by fax (501) 212-8797 or by U.S. mail Attn: Michael Dumas, 1020 West 4th Street, Suite 300, Little Rock, AR 72201.