Medical Bill Review Nurse Case-Manager - RN

At Davies, we get it... you are not just looking for a job, you are looking to build a life and a career. We believe in our people and realize that our success is a direct result of creating a learning atmosphere, leadership opportunities, and promoting from within. We believe that engaging in corporate social activities and working together as a team is a vital part of the Davies culture. 

With a multinational global team, Davies Group is a specialist professional services and technology firm working in partnership with leading insurance, highly regulated, and global businesses.  At Davies Group, we help clients to manage risk, operate core business processes, and to transform and grow. We deliver operations, consulting and technology solutions across the risk and insurance value chain, including excellence in claims, underwriting, distribution, regulation, customer experience, human capital, transformation, and change management.  

As part of Davies Specialty Programs, USIS Inc./AmeriSys specializes in Third Party Claims Administration and Medical Management for Workers’ Compensation and Liability claims. We pride ourselves on our friendly, team-orientated work environment. Our energetic team, supportive leaders, and can-do attitude enhance a sense of collaboration and belonging in our teammates. Our focus is on quality, professional, superior service. This service-driven philosophy, conveyed throughout the organization, means we operate with the customers’ best interests at heart, constantly reinforcing our mission – Service Beyond the Contract.

Are you looking for a company that is Dynamic and Innovative where the teammates are Connected and Succeed Together?  If so, Davies may just be the right choice for you.

Job Overview

As a TCM Medical Bill Review RN on our team. You will be responsible for reviewing Workers’ Compensation provider medical bills via the system for cost containment purposes.   

Opportunity to work from home.

Responsibilities and Duties:

• Utilizing medical expertise and knowledge of the UR process, ICD-10 coding, HCFA billing and CPT and CHPCS coding, review medical bills for appropriateness of codes and fees, also ensuring they are in compliance with state fee schedules and agreements. 
• Review of complex HCFA bills to determine authorization, relation to injury and appropriateness of service. 
• Review of complex UB bills to determine authorization, relation to injury and appropriateness of service 
• Appropriately document all activities, including attachment of emails and records in the computerized system.
• Create, edit and/or revise correspondence as necessary.
• Utilize problem solving skills to identify questionable claims and/or trends during the bill review process. 
• Meet all expectations outlined in the policy and procedure for State of Florida criteria and AmeriSys standards for peer review.
• Maintain patient privacy by ensuring that all medical records, case specific information and provider specific information are kept in a confidential manner, in accordance with state and federal laws and regulations.
• Accurate complete provider bills review according to AmeriSys State of Florida Policies and Procedure in the computer system according to state Workers’ Compensation Fee Schedule rules, with satisfactory volume and error ratio.
• Analyze, review and recommend payment to medical providers based upon statutory rules or guidelines and/or provider reimbursement contract amounts to achieve maximum cost savings.

Experience and Qualifications

• RN with minimum of three years clinical experience in varying hospital specialty units i.e.:  ER, ICU/CCU, Surgery, Trauma, Orthopedic, Neurology, Psychiatric., with a minimum of 2 years’ experience in the areas of Workers’ Compensation, Health and Accident or Auto Liability.
• At least one year’s experience handling Florida Workers’ Compensation case management (contractual requirement).  A minimum of three years’ experience preferred.
• Experienced in Florida Workers’ Compensation Laws & Workers’ Compensation Fee Schedule, ICD-10 and CPT coding procedures, HCPCS coding, HCFA billing, UB billing, Primary Procedure codes.

Knowledge, Skills and Abilities

• Case-management experience mandatory – 1 year Florida Workers’ Compensation.
• Ability to understand state laws and utilization guidelines as they apply to bill review activity.
• Maintains knowledge of current trends, standards and law changes.
• Must be self-directed and able to work independently.
• Excellent organizational skills.
• Detail orientated and motivat