Human Resources Assistant
Jafferjee Brothers Exports (Pvt) Ltd
Job type full-time
Full job description
Hms makes the healthcare system work better for everyoneWe fight fraud, waste, and abuse so people have access to healthcare—now and in the futureUsing innovative technology and powerful data analytics, we help government and commercial payers reduce costs, increase quality, and achieve regulatory complianceWe also help consumers take a more active role in their own healthEach year, we save our clients billions of dollars while helping people live healthier livesAt hms, you will develop new skills and build your career in a dynamic industry while making a difference in the lives of others.
We are seeking a talented individual for a nurse reviewer who will be responsible for performing clinical reviews to determine if the medical record documentation supports the need for the service based on clinical criteria, coverage policies, and utilization and practice guidelines as defined by review methodologies specific to the contract for which services are being providedThis involves accessing proprietary systems to audit medical records, accurately documenting findings and providing policy/regulatory support for determination.
Reviews and interprets medical records and compares against criteria to determine appropriateness and reasonableness of care; apply critical thinking and decision making skills to determine if the medical record documentation supports the need for service while maintaining production goals and quality standards.
Document decisions and rationale to justify review findings or no findings.
Determines approval or initiates a referral to the physician consultant and processes physician consultant decisions ensuring reason for the denial is described in sufficient detail and completed within contractual deadline.
Performs prior authorization, precertification, and retrospective reviews and prepares decision letters as needed in support of the utilization review contract
Assists management with training new nurse reviewers to include daily monitoring, mentoring, feedback and education.
Maintains current knowledge of clinical criteria guidelines and successfully completes required ceus to maintain rn license
Responsible for attending training and scheduled meetings to enhance skills and working knowledge of clinical policies, procedures, rules, and regulations.
Actively cross-trains to perform reviews of multiple claim types to provide a flexible workforce to meet client needs.
Recommends, tests and implements process improvements, new audit concepts, and technology improvements that will enhance production, quality, and client satisfaction
Performs other functions as assigned
Qualifications - external
Knowledge, skills and abilities:
Ability to analyze and evaluate medical information and to apply clinical review guidelines or judgement to make clinical determinations.
Demonstrated experience in medical review, chart audits, and quality improvement processes.
Demonstrated ability to write clear, accurate, concise rationales in support of findings.
Working knowledge of hipaa privacy and security rules.
Ability to multi-task in a fast paced working environment.
Ability to work in a production environment
Ability to build relationships both internally and externally.
Demonstrated proficiency in computer skills, and typing, i.e., microsoft windows, outlook, excel, word, powerpoint, internet browsers, etc.
Demonstrated proficiency in virtual meeting tools i.e., microsoft teams, zoom, etc.
Work conditions and physical demands:
Home based position and you must have a work location within the continental us
This position requires that you provide high speed internet connection and a work environment free from distractions
Ability to work during business hours as this position requires frequent interactions with the team and other departments within hms
Primarily sedentary work in a general office environment
Ability to communicate and exchange information
Ability to comprehend and interpret documents and data
Requires occasional standing, walking, lifting, and moving objects (up to 10 lbs.)
Requires manual dexterity to use computer, telephone and peripherals
May be required to work extended hours for special business needs
May be required to travel at least 10% of time based on business needs
Bachelor's degree in nursing preferred.
Active and unrestricted rn license required
Minimum related work experience:
5+ years clinical experience in an inpatient hospital setting required
2+ years utilization review experience or claims auditing required
Experience using milliman or interqual criteria required
Nothing in this job description restricts management’s right to assign or reassign duties and responsibilities to this job at any time.
Hms is an affirmative action and equal opportunity employer who offers a drug-free workplaceAll qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a disable veteran or veteran of the vietnam era.
Job type: full-time
Pay: from $1.00 per hour
Flexible spending account
Paid time off
8 hour shift
Monday to friday
Clinical: 3 years (required)
Company's facebook page:
Waiting period may apply
Temporarily due to covid-19
Remote interview process