Job Description

SGI Global is seeking Legal Nurse Consultants to provide medical consultation services to the 94 USAOs. To safeguard the public, United States Attorneys' Offices (USAOs) conduct investigations of medical providers to determine whether they are in compliance with the guidelines for Medicare, Medicaid, TRICARE, or other federally funded healthcare programs. Sometimes these investigations arise as qui tam cases, in which a private individual sues on behalf of the United States as a relator. Other times, the USAO identifies a provider based on evidence that raises concerns and initiates the investigation on its own. In either case, the investigation sometimes requires the USAO to review patient files to determine whether services provided were medically necessary. The successful investigation of these matters requires the collection, organization, review and analysis of large volumes of medical records. Legal Nurse Consultants possess the necessary expertise to perform these tasks to assist USAOs in investigating these cases.

Job Duties

• Organizing, including in electronic format, reviewing, and analyzing medical records including, but not limited to, hospital records, physician records, psychology records, physical therapy records, radiological images, reports, and other diagnostic tests;
• Organizing, reviewing, and analyzing records that relate to a provider's submissions to Medicare, Medicaid, TRICARE, or other federally-funded healthcare program; Reviewing and analyzing pleadings, including complaints, deposition transcripts, discovery requests and responses, expert witness reports and or other documents and pleadings provided by the AUSA;
• Identifying records that are pe1iinent to the issues raised in the investigation or lawsuit, as well as any medical records that appear missing or incomplete and providing advice on additional records the AUSA requires for the litigation;
• Summarizing, among other things, medical records, reports, deposition transcripts and preparing medical chronologies;
• Researching medical literature on topics identified by the AUSA or otherwise relevant to the litigation that assist in analysis of the case;
• Identifying medical necessity and whether a given claim was medically necessary;
• Preparing questions or areas of inquiry for the AUSA for depositions or other formal discovery of providers, other witnesses, treating physician(s), and medical expert(s) and other witnesses;
• Preparing reports for the AUSA that include an explanation of pertinent medical terms, medical procedures or surgeries that are relevant to the issues in the case;
• Preparing reports that summarizing the findings and/or conclusions of the Legal Nurse Consultant and/or which set forth some of the facts that need to be determined through investigation/discovery;
• Preparing reports that identify the strengths and weaknesses of the defendant's and the government's case;
• Participating in conferences with the AUSA to discuss the scope of services requested, review records and to explain findings, conclusions and reports;
• Participating at depositions, trial or as otherwise requested by the AUSA;
• Recommending the type(s) of medical experts that should be retained and providing names and contact information for specific experts; and
• Performing other duties related to the investigation or case when requested by the AUSA.

Qualifications:

• Must be Registered Nurses (RNs) with a minimum of 16 years' experience with patient care.
• Must have a Bachelors Degree.
• Experience with medical treatment and medical records, coupled with expertise in organizing, searching and reviewing records for purposes of litigation is required.
• Must have the ability to gather, organize and display medical records and life-care documents in electronically searchable format.
• Nurses with Certified Professional Coder (CPC) certification and/or Certified Inpatient Coder (CIC) certification preferred.
• Nurses with an understanding and working knowledge of Resource Utilization Groups (RUGs) desired.
• US Citizen

SGI Global provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, disability, genetic information, marital status, amnesty, or status as a covered veteran in accordance with applicable federal, state and local laws.

JOB POSTED BY APPLICANTPRO