Job Details

Nursing Specialist
Location: Remote
Hours: 8:00 am-5:00 pm est or 8:30 am-5:30pm Mon-Fri.

This position will review WCMSA case submissions in support of the Workers' Compensation Review Contractor.

Essential Job Duties:
• Review and evaluate proposed Medicare set-aside arrangements, including submitted medical records, to determine if the proposed settlement meets the threshold requirements established for beneficiaries and potential beneficiaries and adequately considers Medicare's interests as pertaining to future medical service needs of beneficiaries.
• Ensure all basic documentation requirements are available or requested via development action prior to review by medical and pharmacy review personnel.
• Render medical/clinical determinations based on professional experience.
• Implement operating rules and CMS policy.
• Audit complex determinations for other clinical review programs utilizing medical records to ensure compliance with the organization's coding procedures and standards.
• Other duties as assigned by management.

Education and Experience Requirements:
• Bachelor's degree from an accredited college or university in Nursing; additional experience would be considered in lieu of degree.
• At least 3 years' related experience required.
• Possess ample medical knowledge and experience with medical terminology, ICD-9/10 Codes, Current Procedure Terminology Codes (CPT) codes, with exposure to applying actual costs and workers' compensation fee schedules in pricing medical items and services.
• Medicare Set-Aside Certified Consultant (MSCC) certification (obtainable within 3 months of hire) preferred.
• Medical/Utilization Review experience preferred.
• Medicare Set-Aside Arrangement experience required.

Additional Knowledge of:
• Healthcare Common Procedure Coding System (HCPCS) coding practices.
• Medicare coverage guidelines.
• Anatomy, physiology, and pharmacology.
• Clinical practice guidelines.
• Utilization review standards and practices.
• State-specific workers' compensation guidelines and pricing structure.
• Health Insurance Portability and Accountability Act (HIPAA) and related healthcare confidentiality regulations.

Essential Duties and Responsibilities:
- Review cases and summarize the facts of each case and assess issues involved in the case to certify or non-certify requested treatments.
- Provide written clinical rationales for Workers Compensation cases.
- Review, organize and identify all medical records provided for workers comp cases.
- Monitor timeliness of reviews to ensure applicable standards are met.
- Consistently meet production and quality standards.
- Perform special projects as assigned such as legal research, general medical research, etc.
- Work on special projects as assigned.
- Become a subject matter expert (SME) using job aides and learning tools.