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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