Nurse Consultant

About the Role

Primarily responsible for thorough review of medical records and other medical documentation to determine appropriate billable services for hospitals to construct an appeal for payment based on medical necessity or payer-specific guidelines or criteria. Responsible for providing clients trending, revenue cycle fail point analysis, and best practice remediation recommendations.

Responsibilities

• Build strong, lasting relationships with clients, payors, and Revecore personnel
• Analyze medical records or other medical documentation to validate services, tests, supplies, and drugs performed for accuracy related to billing for services rendered
• Identify and interpret medical, radiological, laboratory, or other tests and procedures as well as pharmaceutical drugs
• Review and understand managed care contracts, hospital billing statements/bills, and insurance denials
• Research commercial and governmental payor policies, clinical abstracts and studies, and other documentation related to claims payment to evaluate and appeal denied claims
• Perform research regarding denials and effectively communicate information to associates, colleagues, managers, and clients
• Contact insurance companies to obtain missing information, explain and resolve underpayments and/or denials, and arrange for payment or adjustment processing on behalf of the client
• Prepare and submit correspondence such as letters, emails, online inquiries, appeals, adjustments, reports, and payment posting
• Perform denial trending for clients, identify fail points within the revenue cycle and on the payer side, and provide best practice recommendations to clients and Revecore managers
• Maintain regular contact with necessary parties regarding claims status including payors, clients, managers, and other Revecore personnel
• Maintain confidentiality of information in compliance with company policy and HIPAA
• Attend client, department, and company meetings
• Lead client meetings and perform consulting services related to medical necessity of services performed and proper vetting of payers' criteria

Requirements

• College degree or diploma from school of nursing — must be RN
• Clinical nursing experience working in a hospital environment, preferably in ER, Critical Care, or diagnostic services
• Minimum 5 years of related experience and/or training in utilization review or patient accounting
• Highly proficient with Interqual and MCG guidelines and demonstrate appropriate application to claim appeal argument
• Understand patient accounting documents — UB04, EOB
• Working knowledge of Microsoft Office (Word, Excel, Outlook)
• Technical proficiency to work on multiple computer screens and software applications simultaneously
• Able to read and interpret an extensive variety of documents such as medical records, patient care systems, instructions, policies, and procedures in written (in English) and diagram form
• Maintain strong performance in a fast-paced environment with productivity metrics
• Strong analytical skills, attention to detail, and problem-solving skills to identify underpayments and discrepancies
• Experience with healthcare billing software and databases (EPIC, Cerner, Meditech)
• Must reside in the United States within one of the following states: Alabama, Arkansas, Delaware, Florida, Georgia, Iowa, Illinois, Indiana, Kansas, Kentucky, Louisiana, Massachusetts, Maine, Maryland, Michigan, Minnesota, Missouri, Mississippi, Montana, North Carolina, Nebraska, New Hampshire, Ohio, Oklahoma, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Virginia, Wisconsin, or West Virginia

Training

Our comprehensive training begins on your first day and lasts 90 business days. It is led by instructors and incorporates interactive discussions and hands-on activities to accommodate diverse learning preferences.

How We'll Set You Up For Success

• Extensive multi-week training with ongoing support from teammates following training
• Access to a robust knowledgebase for continued reference in your role
• Visibility to your individual performance metrics enables you to set goals
• Computers and necessary work equipment are provided
• Involved management who leans in to support your productivity metrics

Work At Home Requirements

• A quiet, distraction-free environment to work from in your home
• A secure internet connection with speeds >20 Mbps for downloads and >10 Mbps for uploads
• The workspace area accommodates all workstation equipment and related materials and provides adequate surface area to be productive

Benefits

• Paid training and incentive plans
• Medical, dental, vision, and life insurance benefits available from the first day of employment
• Excellent work/life balance
• Employee Resource Groups that build community and foster a culture of belonging and inclusion
• 401(k) matching contributions
• Career growth opportunities
• 12 paid holidays and generous paid time off