Oncology Preservice Review Nurse RN

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About the position

Responsibilities

• Determine that the case is assigned to the appropriate team for review (e.g., Medicare, Medicaid, Commercial)
• Validate that cases/requests for services require additional research
• Identify and utilize appropriate resources to conduct non-clinical research (e.g., benefit documents, evidence of coverage, state/federal mandates, online resources)
• Prioritize cases based on appropriate criteria (e.g., date of service, urgent, expedited)
• Ensure compliance with applicable federal/state requirements and mandates (e.g., turnaround times, medical necessity)
• Review/interpret clinical/medical records submitted from provider (e.g., office records, test results, prior operative reports)
• Identify missing information from clinical/medical documentation, and request additional medical or clinical documentation as needed (e.g., LOI process, phone/fax)
• Review and validate diagnostic/procedure/service codes to ensure their relevance and accuracy, as applicable (e.g., PNL list, EPAL list, state grid, LCDs, NCDs)
• Identify and validate usage of non-standard codes, as necessary (e.g., generic codes)
• Apply understanding of medical terminology and disease processes to interpret medical/clinical records
• Make determinations per relevant protocols, as appropriate (e.g., approval, denial process, conduct further clinical or non-clinical research)
• Review care coordinator assessments and clinical notes, as appropriate
• Identify relevant information needed to make medical or clinical determinations
• Identify and utilize medically-accepted resources and systems to conduct clinical research (e.g., clinical notes, MCG, medical)

Requirements

• Current, unrestricted RN license in your state of residence
• Multiple state licensure (in addition to Compact License if applicable) or ability to obtain multiple state nursing licenses
• 3+ years of Oncology experience as a Nurse
• Computer proficiency, to include solid data entry skills and the ability to navigate a Windows environment
• Access to high speed internet from home (Broadband cable, Fiber or DSL)
• Dedicated workspace for home office set up
• Ability to work schedule listed

Nice-to-haves

• OCN Certification
• Chemo/Bio Certification
• Certified Case Manager (CCM)
• Chemo infusion experience
• ICD Coding experience or solid knowledge of codes
• NCCN experience
• Background in preservice review/utilization review/utilization management
• Reside in Mountain or Pacific time zones

Benefits

• Comprehensive benefits package
• Incentive and recognition programs
• Equity stock purchase
• 401k contribution

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