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RN-Medical Review Program Specialist
 
JOB CODE:120150
 
PAY GRADE:2220
 
SALARY RANGE:$40,308 - $55,796
 
LOCATION OF WORK
Parish Attorney
 
GENERAL DESCRIPTION
Under the direction of the Risk and Claims Manager, performs highly responsible and professional work reviewing and analyzing medical charges billed to the City-Parish for work related accidents and injuries. Work involves responsibility for isolating questionable procedures, charges and billing errors through a retrospective utilization review of Workers' Compensation related medical claims. Work is performed within the scope of established policies, rules and regulations of the City-Parish. Work is reviewed through conferences, reports and results obtained. Performs other work as requested.
 
ESSENTIAL WORK TASKS
Performs a retrospective utilization review of hospital, physician, physical therapy, and related medical bills selected for audit; isolates questionable charges or procedures that may be billed in error. Provides significant information based on various medical diagnoses including corresponding procedures and treatments, lengths of stay, lengths of visits and proper medical intervals. Consults with adjusters, physicians and medical personnel to ensure proper interpretation of medical diagnosis and related charges; reviews related pertinent medical information. Analyzes, observes and notes any medical bills submitted with erroneous charges and for inappropriate patterns of treatment; informs superiors of repetitive questionable billing errors from specific medical providers. Serves as medical advisor for workers' compensation appeals and related medical negotiations, mediations and meetings. Assists attorneys in preparation for medical depositions and trial by reviewing and analyzing medical related documentation. Works closely with department personnel to ensure proper payment of work related medical claims; assists adjusters with evaluation of future exposures on claims based on medical audit.
 
KNOWLEDGE, SKILLS, AND ABILITIES
Knowledge of medical terminology Knowledge of utilization review techniques Knowledge of workers' compensation fee schedules. Skill in the operation of modern office equipment and in the use of complex computer applications. Ability to analyze and review information and identify options and apply solutions. Ability to interpret clinical/medical records. Ability to express ideas clearly and concisely, orally and in writing, to groups and to individuals. Ability to establish effective working relationships with others including vendors, providers and employees. Ability to apply good work habits such as punctuality, reliability, preciseness, and dependability in order to effectively complete assigned tasks and contribute to the smooth operation of the department and division.
 
MINIMUM REQUIREMENTS
EDUCATIONAL AND EXPERIENCE
Bachelor's degree in nursing, and two years acute care nursing experience.
 
SUBSTITUTIONS
None.
 
CERTIFICATIONS/LICENSES
Possession of a valid Registered Nurse license issued by the Louisiana State Board of Nurse Examiners.
 
OTHER JOB ASPECTS
None.
 
NOTE:
The work examples described in this specification are intended only as an illustration of the various types of work that may be performed. The omission of specific statements of duties does not exclude them from job performance requirements if the work is similar, related or a logical assignment to the job.