Medlogix, LLC delivers innovative medical claims solutions through a seamless collaboration of our Medlogix® technology, our highly skilled staff, access to our premier health care provider networks, and our commitment to keeping our clients’ needs as our top priority. Medlogix has a powerful mix of medical expertise, proven processes and innovative technology that delivers a more efficient, disciplined insurance claims process. The result is lower expenses and increased productivity for the auto insurance and workers’ compensation insurance carriers; third party administrators (TPAs); and government entities we serve.
OVERVIEW:
The
Audit Field Nurse performs medical auditing functions for commercial insurance carriers and self funded organizations to include retrospective and outpatient audits of suspected issues. Reviews include but are not limited to utilization of services/medical necessity guidelines, billing, and coding and documentation accuracy. Follows investigation protocols and responds to reported, suspected or confirmed non-compliance.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
- Meets education requirements for ongoing professional training to maintain current state licensure and national certifications where applicable
- Practices within the scope of licensure in accordance with Company policies, practices, procedures and State/Federal laws
- Participates in and attends compliance, departmental and payer meetings in response to audits conducted and fosters open lines of communication within the organization.
- Assists in the development and monitoring or special compliance projects with manager and member s of the Bill Review departments. Provides education and feedback to areas in regards to audits conducted.
- Performs auditing functions on a retrospective basis as assigned in accordance within departmental Service Level Agreements and within Workers' Compensation and Automobile guidelines (legislative, carrier specific etc.)
- Will perform Audit with application of medical necessity guidelines based on nationally recognized criteria
- Completes audit reporting with clerical and mailing support in accordance within departmental Service Level Agreements and guidelines to include narrative reports, specific CPT code worksheet recommendations, time and expense reports etc.
- Maintains established productivity and quality standards
KNOWLEDGE:
- Knowledge of corporate and departmental policies and procedures
- Knowledge of basic math, arithmetic and their applications.
- Knowledge of medical coding, i.e., CPT codes, ICD-9 codes, HCPCS codes
- Knowledge of office equipment, i.e., fax machine, copy machine, printer, e-copy scanner, telephone, calculator
- Must be knowledgeable in Commercial Insurance and billing and payment criteria
- Knowledge of NJ PIP Rules and Regulations
EEOC STATEMENT:
Medlogix provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.'
