Medical Claims Review Nurse

Concentra Preferred Systems (CPS), a wholly owned subsidiary of Concentra Corporation, is the nation's largest outsourced provider of specialized cost containment services for the Healthcare industry. The company employs over 750 professionals across the United States, with headquarters in Naperville, Illinois and operations offices in Weymouth, MA., Frederick, MD., Rockville, MD., Stroudsburg, PA., Salt Lake City, UT., and Dallas, TX. Over its 13 year history, CPS has generated approximately $3.3 billion in savings for its clients, a figure without peer in the cost containment sector. CPS provides technology and services that reduce claim transaction costs for healthcare payors. CPS services are designed to lower medical and administrative expenses associated with contracted and non-contracted medical care. The company has established electronic interfaces with virtually all of the largest health insurance carriers and HMOs in the U.S. as part of their network management and adjudication process.

Concentra is an equal opportunity employer.

JOB SUMMARY:
Review bills prior to assignment to identify claims that have a high probability of successful audit.


MAJOR DUTIES AND RESPONSIBILITIES:
' Utilize professional training and experience to interpret hospital-billing strategies
' Update case notes with screening results for auditing process
' Contact providers, if necessary, to clarify information about services performed during admission
' Maintain a positive working relationship with department members, client and Client Services by complying with client turn-around time requirements

Process:
' Review claims for patient gender, dob, patient status, dos, length of stay
' Provide/lookup DRG and C2C values
' Check Procedure and Diagnostic codes
' Monitor medical and surgical bills for over-utilization, excessive charges and/or units, inappropriate billing practices
' Evaluate documentation, reference materials, system information, etc. in order to make appropriate decisions on complex claims
' Adhere to specific tat based on type of client
' Review Itemized bills and apply appropriate revenue centers to charge description
' Perform other duties and projects as assigned

' Assist in the facilitation of Medical Terminology training classes for other colleagues.
' Other duties as assigned

Education and Experience:



' RN with screening and/or audit experience

' Recent clinical experience

' Familiarity with UB's, itemized bills, and ICD-9 codes

' Computer literacy

' Excellent organizational skills

' Excellent interpersonal, oral, and written skills