QA Nurse

Company:Concentra Location:Woodbridge, NJ 02451 Job Category:Quality Assurance/Safety Reference Code:conc-00018459 Serving the occupational, auto and group healthcare markets, Concentra provides employers, insurers and payors with a series of integrated services that include employment-related injury and occupational healthcare, in-network and out-of-network medical claims review and repricing, access to preferred provider organizations, first notice of loss services, case management and other cost containment services. Concentra provides its services to approximately 136,000 employer locations and 3,700 insurance companies, group health plans, third-party administrators and other healthcare payors. The Company has over 300 medical centers located in 40 states. It also operates the Beech Street and FOCUS networks which include 544,000 providers, 52,000 ancillary providers and 4,400 acute-care hospitals nationwide. Concentra is an Equal Opportunity Employer.NOTICE:Employment Verification Done. Federal law requires all employers to verify the identity and employment eligibility of all persons hired to work in the United States. JOB SUMMARY: Candidate needs to have full knowledge of medical utilization review. Must be detail oriented and able to work independently. Must possess professional demeanor and have good communication skills to interact with clients of AIS. MAJOR DUTIES AND RESPONSIBILITIES:'Review first party nurse review flags/processing to determine accuracy of decision-making 'Review third party nurse processing to determine accuracy of decision-making, completeness of TPAA and accuracy in bill processing'Review PHAD processing for completeness of issues, spelling, grammar and sources. '100% QA on all new nurse hires'Enter quality information into QA tool'Interact with nurses and team members.'Interact with nursing supervisors/managers in retraining and/or 'Assist QA director with nurse and/or consultant education. QUALIFICATIONS:'CHCQM certification is preferred'Medical bill review experience/claims processing in auto or workers compensation arena is requiredCPT, ICD-9, HCPCS literate'Detail oriented'Ability to work well under time demands 'Case Management experience in a medical management environment helpful'At least one year of Quality Assurance/Utilization review required'Computer literate (WORD, Excel, Power Point. Lotus)'Excellent verbal and written communication skills'Able to interact with clients and research issueWORKING CONDITIONS/PHYSICAL DEMANDS: 'Office/at-home environment To Apply, Click here The Circle of Success.Concentra's mission is to improve the quality of life by making health care accessible and affordable. We serve the occupational, urgent care, and automobile markets with a wide range of services: Employment-related injury care and occupational health care provided at more than 320 Concentra-managed medical centers in 40 states. Urgent care services provided to the public at selected medical center locations in key metropolitan areas. Specialty occupational health care solutions provided to employers through on-site locations, by traveling to the workplace, or via the Internet and telephone. Automobile claim services through our Auto Injury Solutions division. The Circle of Opportunity. Concentra manages more than 320 medical centers in 40 states and continues to expand our geographic reach through the acquisition of established medical providers and the development of new locations. We are actively expanding our Urgent Care service offering by adding this capability to existing Concentra Medical Center locations. Our specialty health services, which we refer to as our Health Solutions division, is rapidly expanding as we identify new ways to provide customized health care solutions for employers and their workers.The Circle of Teamwork. Concentra brings together talented, compassionate people to solve the highly complex issues of health care delivery, accessibility, and affordability. Every day, we make a difference in the lives of thousands of people through our ability to improve health care efficiency and outcomes. Your career path and development can be on-the-go at Concentra, where you can advance as far as your ideas and performance can take you.