Review and Evaluation Nurse

Job Description

Review and Evaluate the medical necessity, appropriateness, quality, quantity, adequacy and compensability of medical care and services rendered by Hospice providers under the Medical Assistance Program. The nurse is responsibile for the review and evaluation of medical information and examination of medical records and other documentation to assure that eligible medical assistance recipients receive appropriate and quality medical care. The Medical Assistance Program must be properly billed, and that the provider and/or recipient fraud, abuse and waste is detected.

 

Requirements

Able to prepare correspondence and reports.

Comprehend and apply regulations, policies and standards.Establish and maintain effective working relationships.

Carry out instructions and complete assignments.

Ability to conduct field work, desk and telephone reviews.

Travel to facilities/providers sites to conduct reviews and attend training and meetings as required across the state (Includes overnight stays)

Communicate effectively (verbally and in writing) with coworkers, management, Office of General Council, other agencies, facility staff and other medical assistance providers to review and discuss cases.

Enter essential data into the computer.

Physically traverse stairs, lift laptop, printer and related equipment, walk long distances and sit for long periods of time.

Review and evaluate provider documentation to determine compliance with Medical Assistance regulations.

Testify at administrative/legal hearings and to defend Department decisions.

Maintain discretion and confidentiality.

 

Minimum Qualifications and Education Requirements

Registered Nurse