Case Review Specialist (RN)

Service Line: State & Corporate Services

Status: Non-Exempt

OVERALL SHORT DESCRIPTION
Under direct supervision, is responsible for conducting specialized medical record reviews for appropriate utilization management, quality of care and DRG validation in accordance with established criteria, exercising professional medical judgment.  Responsible for ensuring accurate and timely entry of required SDPS CRIS case review outcomes. Responsible for ensuring that all case review activities are completed within CMS required time frames. Participates as a member of Case Review Team, fully participating in the efficiency and effectiveness of case review activities and recommending improvements in workflow processes.

ESSENTIAL FUNCTIONS

1. Conduct concurrent and retrospective, mandatory case review of beneficiary complaints, EMTALA, NONC, referrals, sanctions, ALG requests and case review and data collection activities using appropriate methodologies, protocols, criteria, and professional medical judgment ensuring CMS requirements and timeframes are met or exceeded.
2. Recognize QIO processing authority through verification of Medicare eligibility and provision of Medicare services; coordinate appropriate request of medical records and refers those cases that fall outside QIO review authority to the appropriate entity.
3. Determine the need for medical records and coordinate request for same; review medical records to identify concerns and formulate appropriate questions for physician review; prepare preliminary and final letters of concern; review responses received and incorporate appropriate information into physician reviewer questions, face-to-face interaction with HSAG physicians, and final letters.
4. Compose disclosure letters intended for Medicare Beneficiary consumption using layman terminology and adhering to confidentiality regulations.
5. Adhere to department policies and procedures and CMS guidelines to ensure timely, accurate, reliable, and consistent review outcomes.
6. Perform accurate and timely data entry of review results using CRIS.
7. Attend the Case Review Team meetings, fully participating in the efficiency and effectiveness of case review activities and recommending improvements in workflow processes.
8. Participate in "on-call" activities as required by current CMS contract.

ACCOUNTABILITY
Accountable for the timeliness, completeness, accuracy, and quality of all assigned functions and tasks.

WORK CONDITIONS
In this position the employee may be subject to environmental conditions related to vehicular and air travel to and from locations.

PHYSICAL AND MENTAL DEMANDS/COMPETENCIES

1.  Ability to discern a supervisor's expectations without receiving specific instructions or assignments regarding how the job should be carried out.

2. Ability to attend to detail and discern possible cause and effect from medical and surgical treatment events.

3. Ability to formulate approaches to solving specific problems.

4. Ability to communicate information both written and verbal in a clear, concise, and accurate manner.

5. Ability to simultaneously plan and manage numerous activities effectively and in a timely manner, paying attention to priorities and details and maintaining accurate documentation of events.

6. Ability to use a personal computer and appropriate software programs.

7. Ability to adhere to established company confidentiality policies.

8. Ability to adapt to different situations involving a variety of duties characterized by frequent change; tolerate and use opposing views.

9. Ability to cope with stressful situations by maintaining adequate performance when confronted by pressures of deadlines and time limits.

10. Ability to serve as a patient advocate to facilitate the most rapid resolution of the concern while being attentive to serious quality-of-care issues.

QUALIFICATIONS

1. Health Care Professional with a Bachelors degree (preferred) in appropriate science of related discipline, or equivalent combination of education and experience. RN preferred.
2. Minimum of five years health care experience in acute-care setting.
3. Minimum of one year QIO experience in Mandatory Review Activities.
4. Possess a general understanding of the changing health care marketplace.
5. Proficient with Windows computer environment.
6. Demonstrated excellence in oral and written communication and interpersonal skills.

DISCLAIMER
This is not necessarily an exhaustive list of all responsibilities, skills, duties, requirements, efforts, or working conditions associated with the position. While this is intended to be an accurate reflection of the current position, management reserves the right to revise the position or to require that other or different tasks be performed when circumstances change (e.g., changes in personnel, emergencies, workload, technological developments, or company priorities).

APPLY FOR THIS POSITION.

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