Nurse Sr Professional @ Computer Sciences Corporation
Job Description
Essential Job Functions
Conducts clinical reviews of medical records during the course of fraud investigations or other benefit integrity initiatives such as requests for information or in support of proactive data analysis.
Applies Medicare guidelines in making clinical determinations as to the appropriateness of payment coverage.
Reviews information contained in Standard Claims Processing System files (e.g., claims history, provider files) to determine provider billing patterns and to detect potentially fraudulent or abusive billing practices or vulnerabilities in Medicare payment policies.
Utilizes extensive knowledge of medical terminology, ICD-9-CM, HCPCS Level II and Current Procedural Terminology (CPT) coding along with analysis and processing of Medicare claims. Coordinates and compiles a written Investigative Summary Report upon completion of the records review.
Provides expert witness testimony as required.
Qualifications
Basic Qualifications
Graduate from an accredited school of nursing and has an active license as a Registered Nurse (RN)
Must have no adverse actions pending or taken against him/her by any State or Federal licensing board or program; and must have no conflict of interest (COI) as defined in 1154(b) (1) of the Social Security Act.
Must have and maintain a valid driver's license by his/her state of residence.
At least 5 years utilization / quality assurance review and ICD-9-CM/CPT coding experience DRG codes.
Knowledge of, and the ability to correctly identify, Medicare coverage guidelines.
Other Qualifications
Communication skills
Ability to use Microsoft Word, Excel, Internet applications and databases </LI><LI>Previous Medicare experience preferred
Organization and time management skills
Leadership skills to guide and mentor the work of less experienced personnel
Ability to work in a team environment
Ability to keep sensitive and confidential material private
Willingness to travel
Job Benefits
not provided
Job Summary
Job Title:     Nurse Sr Professional
Company:     Computer Sciences Corporation
Location:     US - TN, NASHVILLE, 37201