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SalaryIf you are interested in employee ownership and growing your professional nursing career in a non-clinical setting, The van Halem Group is the perfect fit for you!
Who are we at The van Halem Group?
We are an Atlanta-based firm that has grown to become one of the nation's most respected healthcare audit and consulting firms. At The van Halem Group we focus on assisting providers navigate complex issues related to audits, appeals, enrollment, and compliance. Our team of experts focuses on one mission: commitment to providing comprehensive, fair, confidential and sound counsel to healthcare providers and suppliers, attorneys, government agencies and their contractors regarding healthcare laws and regulations.
Clinical Nurse Reviewer Summary
Position Summary
As a Clinical Reviewer for The van Halem Group – A Division of VGM Group, Inc. Employees must be a licensed nurse or a respiratory therapist with experience in Medicare, Medicaid and/or commercial payer policies and Medical Review, with specific knowledge of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) preferred. The position requires reviewing patient files to determine if payer coverage criteria has been met and educating clients on coverage policies and requirements. Information gathered is then provided to the client, including overall summaries of the patient file as well as issues and recommendations.
Responsibilities/Duties of the Job
The Clinical Reviewer is responsible for review of patient medical files to determine payer coverage criteria and deliver this information in an informative and educational way to clients.
Duties Include:
- Review of clients’ patient medical files to determine coverage prior to the client billing insurance for claim payment
- Knowledge of contract specific guidelines
- Ability to interpret healthcare insurance guidelines, rules, and regulations
- Excellent verbal and written communication skills
- Answers questions from staff and clients
- Follows strict HIPAA confidentiality guidelines
- Manage cases and input medical decisions in the Company’s case management system
- Ensure orders are setup with accurate codes and quantities
- Identification of client training needs
- Development of training and education materials
- Deliver training and education to clients and potential clients including in-person seminars, webinars, written material, PowerPoint presentations, and other various methods
- Any other duties as deemed appropriate by the management
Position Qualifications
Must hold a valid nurse or respiratory therapist license and relevant experience in reviewing documentation for DMEPOS claims.
- Proficient in payer policies and medical review or benefit integrity
- Additional certification as a Certified Professional Coder is preferred, but not required
- Excellent computer skills including Excel, Word, and other Microsoft Office products
- Excellent communication skills, including oral and written communication
- High degree of organization and administrative process skills including great attention to detail
- Capacity to work independently with minimal direction
- Evidence of learning quickly and ability to build on existing business foundations
- Ability to administer and coordinate across multiple tasks and deadlines
- Advanced professionalism and ability to maintain strict confidentiality of company and employee information
- Ability to work in a fast-paced environment with multiple priorities
As an employee of vHG a company of the VGM Group, Inc. one can interact with all levels of the organization. In doing so, the right person will see the opportunity for personal and professional growth and take the appropriate steps to make that happen for their benefit and that of The VGM Group.
Physical Requirements
- Sitting for long amounts of time
- Using technology efficiently such as computers, phones, misc. office equipment
- Standing
- Compensation:Highly competitive wage.
- Company Ownership: VGM is 100% employee-owned, meaning employees can earn an annual gift of VGM stock equaling a portion of what you make.
- Fantastic Benefits: 401k and ROTH 401k with up to 3% company match, Health Benefits, HSA options - single to family, Dental, Vision, Short and Long-Term Disability, Term Life and Voluntary Life Insurance and a physician network where you reside.
- Involvement: Ability to participate in Employee Get Connected Groups, (VGM Young Professionals, Garden Club, Women in Leadership) Volunteering, Companywide celebrations, and more.
- Work-life Balance: Paid Holidays with the Holiday of your Choice benefit, Paid maternity and Paternity leave, Foster and Adoption Assistance.
This job description reflects the general duties of the job but is not a detailed description of all duties which may be inherent to the position. Related additional duties may be assigned to the individual Associate.
VGM Group, Inc. 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.
This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.
