**Please make sure your application is complete, including your education, employment history, and any other applicable sections. Initial screening is based on the minimum requirements as defined in the job posting, such as education, experience, licenses, and certifications. Your experience should also address the knowledge, skills and abilities needed for the role. Incomplete applications will not be considered.**

*This position is located Remote, Texas*

Position Purpose:

Performs moderately complex or complex (journey or senior level) work. Conducts contract activities in accordance with state agencies and the state policies and requirements. Works under general supervision, with moderate latitude for the use of initiative and independent judgment.

Essential Responsibilities:

Obtains, reviews, and may organize and analyze medical records to determine compliance with review and program policies.
Documents review findings and recommends adjustments or denials of services for each claim detail.
Obtains physician/dentist decisions on medical necessity-related findings.
Composes narrative summary of record review findings and writes education or recoupment letters as directed.
Works with State customer on review findings.
Performs actions for case disposition which may include, but is not limited to, assisting in conducting provider education and may perform prepayment review and adjudicating claims based on results of record review
Documents and tracks provider case review activities, case dispositions, and may perform prepayment review activities.
Performs reviews of cases referred from state agencies and prepares report of findings.

Minimum Qualifications

Education

Diploma Nurse or Associates degree in nursing or related discipline from an accredited college or university

License and Certification

Registered Nurse (RN) with an active Texas license
Coding Certification, preferred

Experience

Three (3) to four (4) years healthcare
Two (2) years clinical in a healthcare setting
One (1) to two (2) years utilization management, retrospective review, medical record review, or claims review
Surveillance and Utilization Review (SUR), preferred

Benefits

TMF offers an excellent benefits package, including:

Medical, dental, vision, life, accidental death and dismemberment, and short and long-term disability insurance
Section 125 plan
401K
Competitive salary
License/credentials reimbursement
Tuition Reimbursement

EOE Minorities/Females/Vet/Disability

Job Type: Full-time

Benefits:

401(k)
401(k) matching
Dental insurance
Health insurance
Paid time off
Referral program
Vision insurance

Location:

Texas (Required)

Work Location: Remote

TMF Health Quality Institute

New Jobs

Records Review/Prepayment Nurse