Registered Nurse

Company: P3 Health Group Management, LLC
Location: Henderson
Posted on: May 3, 2021

Job Description:

People. Passion. Purpose.

At P3 Health Partners, our promise is to guide our communities to better health, unburden clinicians, align incentives and engage patients. We are a physician-led organization relentless in our mission to overcome all obstacles by positively disrupting the business of health care, transforming it from sickness care into wellness guidance.

We are looking for a Medical Claims Review Nurse. If you are passionate about your work; eager to have fun; and motivated to be part of a fast-growing organization in Las Vegas, Nevada, then you should consider joining our team.

Overall Purpose

The Medical Claim Review (MCR) Nurse provides a variety of services with respect to medical care review, cost containment, claims review, appeals and grievances, and analytical reporting. As part of our Claims Team, the MCR Nurse employs best practices and principles to ensure high quality and cost-effective assurance standards.

Essential Duties and Responsibilities

• Conducts retrospective case reviews for appropriateness/quality of treatment and bill accordingly, as well as medical
• Provides statistical case reviews and generates utilization reports
• Examines DRG pre-certification, certification of admissions, and continued stay
• Acts as a liaison between Medical and Claims departments regarding medical review issues
• Communicates with other departments and personnel to facilitate proper adjudication of claims
• Reviews medical information from various facilities for medical necessity
• Maintains medical standards for all clients
• Communicateswith hospitals, physicians, and subscribers regarding certification of hospital admissions and outpatient services
• Meets with Management team about current processes and implementing new processes
• Develops relationships with physicians, healthcare service providers, and internal and external customers to help improve health outcomes for members
• May access and consult with peer clinical reviewers, Medical Directors and/or delegated clinical reviewers to help ensure medically appropriate, quality, cost effective care throughout the medical management process
• Educates the member about plan benefits and contracted physicians, facilities and healthcare providers
• Refers treatment plans/plan of care to peer clinical reviewers in accordance with established criteria/guidelines and does not issue medical necessity non-certifications
• Maintains compliancy with regulation changes affecting utilization management
• Reviews patients records and evaluates patient progress
• Documents review information in computer
• Communicates results to the appropriate parties and enters the appropriate billing information for services
• Responds to complaints per UR guidelines
• Records and reports all information within scope of authority
• Performs analytical reporting from a variety of reports, client charts and other documents and participates in developing strategies for medical cost containment, maintaining quality of care and client satisfaction
• The MCR Nurse will participate in the following activities either in tandem or at the direction of the department supervisor or management team
• Actively participate with management to develop business process analyses
• Develops recommendations for appropriate solutions
• Validates and perform quality assurance
• Creates or revise analytical approaches to reflect current priorities and circumstances
• Develops, analyzes, and implements project plans
• Mobilizes project teams
• Develops plans or proposals that include cost/benefit analysis, policy, and financial, operational, and organizational implications
• Exercises discretion, tact, and judgment when working with internal and/or external departments.

Knowledge, Skills, & Abilities:

• Excellent communication skills, both verbally and in writing are critical
• Knowledge of principles, practices and current trends in nursing as well as best practices in quality assurance.
• Knowledge and application of state and federal laws, statutes, and regulations; excellent analytical skills; ability to work as part of a team and be self-directed; and intermediate knowledge of Word and Excel.
• Communication qualifications include demonstrated verbal and written communication skills and ability to present information effectively, tailor presentations to a wide variety of audiences (including executive management), present complex concepts and recommendations clearly for management decision-making purposes.
• Ability to comprehend, interprets, and applies Business Rules Management System (BRMS) policies; ability to continually adjust in a dynamic environment; and ability to work as a member of a team.

Education and/or Experience: Graduate from accredited school of nursing with at least two years acute clinical experience with at least one year of case management or utilization review experience.

Language Skills: Ability to read, speaks, and writes effectively in English. Ability to interpret documents such as safety rules, memos, letters, and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before customers or employees of organization. Ability to effectively address or resolve customer service issues within guidelines of the position.

EQUAL OPPORTUNITY EMPLOYER

We're an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran or disability status.

DIVERSITY & INCLUSION

At P3, we recognize and appreciate the importance of creating an environment in which all team members feel valued, included, and empowered to do their best work and bring great ideas to the table

Every P3 family member's unique experiences, perspectives, and viewpoints are valued and support our ability to deliver the best possible experience for our patients, providers, payers, partners, and each other.

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Keywords: P3 Health Group Management, LLC, Henderson , Registered Nurse, Other , Henderson, Nevada