Gainwell Technologies LLCSummary
Under the direction of the Nursing Administrator of the Clinical Program Integrity & Compliance Section, this highly responsible professional position must exhibit responsible clinical and professional judgment and act under general supervision.
This position serves as an Office of Inspector General’s Nurse Consultant for pre-payment activities. This position conducts the review of clinical and financial pre-payment compliance review activities in the Office of the Inspector General (“OIG”) to detect, combat, and eliminate fraud, waste and abuse in the Medicaid program. This position also has responsibilities in the areas of consulting on the development and implementation of pre-payment review policies and guidelines designed to promote program and departmental objectives in OIG. This position requires the ability to perform comprehensive medical records reviews and perform analysis of complex datasets and systems. This position requires exceptional written and oral communications, problem-solving skills, clinical experience in multiple settings of varying complexity and experience with children and adult populations.
This position will require knowledge of federal and state regulations, Medicaid and Medicare programs, systems analyses and research methods. This includes the ability to develop, establish and implement prepayment review criteria within multiple service areas. In addition, the ability to process prepayment reviews of Medicaid services according to established medical necessity criteria, administrative code and other requirements. Your role in our mission
What we're looking for
- Assesses the physical and psychosocial health status of employees through collection of health data such as, complete history taking, physical examination, initiation and interpretation of laboratory tests and initiation of other diagnostic tests as determined by protocol.
- Identifies problems based upon examination findings to determine the need for immediate nursing intervention, consultation and referral to other health team members.
- Monitors and manages the care of stabilized chronic conditions under direction of upper management or personal physician; ensures that appropriate medical assistance is available, when needed. May train employees in the self-management of health problems.
- Investigates quality and quantity of provided health care to determine adherence with company and governmental policies. Provides nursing care for complex occupational illnesses and injuries at various worksites including emergency care and referrals.
- Maintains health related documentation such as employee medical records. Tracks and records exposure to hazardous environments or chemicals and common injuries to ensure prevention of future occurrence. Provides counseling on routine health subjects and referrals to other health care professionals.
- Participates in decisions regarding the formulation of policies, procedures and protocols for the management of specific health problems; ensures that medical issues related to employee health and occupational environment are addressed in a timely manner.
- Interfaces with line management, safety and industrial hygienists, and human resources personnel regarding resolution of pending medical claims or cases related to on-site accidents or injuries, to ensure resolution in a timely manner.
- Plans and evaluates health education programs. Establishes, maintains, and reviews nursing record keeping systems to ensure confidentiality and adherence to legal requirements.
- Supervises Guides less experienced staff in the delivery of health care consistent with nursing practice standards and established company policies to ensure that appropriate care is provided in a timely manner.
What you should expect in this role
- Degree in nursing
- Three (3) or more years of nursing experience
- Experience working with case management practices and clinical record review
- Current Wisconsin license as a Registered Nurse
- utilization review and procedure coding experience is preferred
- Remote (work from home) with occasional travel required to the office at 1 West Wilson, Madison, WI occasionally
- Must be a resident of Wisconsin
- Must be a currently licensed Registered Nurse
- Case Management
- Certified Medical Assistant
- Certified Nurse Practitioner
- Claim Processing
- Clinical Works