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Position Description

Pinnacle Business Solutions - EXEMPT POSITION DESCRIPTION

Position:  Review Analyst R.N. -I
Reports To: 
Division:  zMedical Review S3 (5013)
Company:  PINNACLE
Location:  Label
Job Code:  39601X
Min Salary:   52100
Date Posted:  8/6/2012

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Position Specific Requirements: Medicare Medical Review Part A and Part B a plus

Job Summary
This position is accountable for the clinical review of claims for Medicare Advantage to identify claims conformance with Medical Necessity, National Coverage Decisions, Local Coverage Decisions and the Medicare Advantage Plan Document.  

Nature & Scope
With the increasing importance of cost containment, medical review is involved in helping to achieve corporate financial stability.  This position is accountable for reviewing and analyzing claims for the Medicare Advantage operation1.  The review occur through targeted medical review (probes) and focused medical review (complex reviews) on claims identified through edits and audits. Provider notification, feedback and education are also essential parts of the review process.

Minimum Job Requirements

Minimum Job Requirements

  • 1. Registered Nurse license, State of Arkansas
  • 2. Experience in nursing, to include a broad background in various facets of nursing (emphasis in medical/surgical or critical care areas).
  • 3. Experience with personal computers for word processing, Power Point, and spreadsheet applications. Microsoft Word and Excel preferred.
  • 4. Related medical review experience.
  • 5. Must be able to professionally communicate both orally and in writing. Writing samples may be required.
  • 6. Must have a broad knowledge of the current trends in health care, including new medical and surgical procedures, medical use products and new drugs.
  • 7. Must have broad knowledge of Medicare/Medicare Advantage reimbursement and coverage policies.
  • 8. Must have broad knowledge of the enterprise, insurance law, ICD-9, ICD-10, and CPT-4 coding procedures. Coding certification is preferred.
  • 9. Must be able to collect information and formulate conclusions independently, and to make sound judgments and decision based on facts and guidelines.
  • 10. Must have the ability to analyze problems, develop solutions, and plan, organize and control work for maximum efficiency.

Security Requirements
This position is identified as level three (3). This position must ensure the security and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained. The integrity of information must be maintained as outlined in the company Administrative Manual.

Segregation of Duties
Segregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. This position must adhere to the segregation of duties guidelines in the Administrative Manual.

1. Conduct targeted or focused reviews on either a prepayment or post-payment basis, including clinical review of claims.
2. Ensure Medicare Advantage claims are adjudicated according to accepted standards of medical practice as well as regulatory constraints.
3. Adjudicate claims in the Medicare Advantage system with appropriate entries, including to POWER (Paperless Operational Workflow Electronic Routing) if applicable.
4. Initiate correspondence to physicians/suppliers requesting additional information on questionable claims.
5. Prepare and present direct one-on-one or specialty provider education resulting from medical review.  
6. Meet performance standards in all Key Result Areas.
7. Maintain and update knowledge of new medical and surgical procedures and products, new drugs, and general trends in health care delivery.
8. Participate in and develop special projects as assigned.
9. Participate in development of desk procedures, audit, compliance and innovative activity.
10. Perform other duties as assigned.  
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