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Records Review/Prepayment Nurse

  • TMF Health Quality Institute
  • Remote, Texas
  • Jan 28, 2025
Full time Health Care

Job Description

TMF Health Quality Institute

 www.tmf.org

 

Please visit our Career Center to Apply and View the Full Job Description

 https://jobs.tmf.org/

 

**Please make sure your application is complete, including your education, employment history, and any other applicable sections. Initial screening is based on the minimum requirements as defined in the job posting, such as education, experience, licenses, and certifications.  Your experience should also address the knowledge, skills and abilities needed for the role. Incomplete applications will not be considered.**

 

*This position is located Remote, Texas*

 

 

Position Purpose:

Performs moderately complex or complex (journey or senior level) work.  Conducts contract activities in accordance with state agencies and the state policies and requirements.  Works under general supervision, with moderate latitude for the use of initiative and independent judgment.

                                                                                                                                    

Essential Responsibilities:

  • Obtains, reviews, and may organize and analyze medical records to determine compliance with review and program policies.
  • Documents review findings and recommends adjustments or denials of services for each claim detail.
  • Obtains physician/dentist decisions on medical necessity-related findings.
  • Composes narrative summary of record review findings and writes education or recoupment letters as directed.
  • Works with State customer on review findings.
  • Performs actions for case disposition which may include, but is not limited to, assisting in conducting provider education and may perform prepayment review and adjudicating claims based on results of record review
  • Documents and tracks provider case review activities, case dispositions, and may perform prepayment review activities.
  • Performs reviews of cases referred from state agencies and prepares report of findings.

 

 

Minimum Qualifications

 

Education

  • Diploma Nurse or Associates degree in nursing or related discipline from an accredited college or university

 

License and Certification

  • Registered Nurse (RN) with an active Texas license
  • Coding Certification, preferred

 

Experience

  • Three (3) to four (4) years healthcare
  • Two (2) years clinical in a healthcare setting
  • One (1) to two (2) years utilization management, retrospective review, medical record review, or claims review
  • Surveillance and Utilization Review (SUR), preferred

 

 

Benefits

TMF offers an excellent benefits package, including:

 

  • Medical, dental, vision, life, accidental death and dismemberment, and short and long-term disability insurance
  • Section 125 plan
  • 401K
  • Competitive salary
  • License/credentials reimbursement
  • Tuition Reimbursement

 

EOE Minorities/Females/Vet/Disability

About TMF Health Quality Institute

TMF Health Quality Institute focuses on promoting quality health care through contracts with federal, state and local governments, as well as private organizations. For more than 50 years, TMF has helped health care providers and practitioners in a variety of settings improve care for their patients.

TMF was chartered in 1971 as a private, nonprofit organization of licensed physicians (MDs and DOs) to lead quality improvement and medical review efforts in Texas. Originally known as the Texas Medical Foundation, the company changed its name to TMF Health Quality Institute in 2005 to reflect the expansion of its work throughout the nation.

TMF’s programs and services—ranging from quality improvement consulting and technical assistance to research, data analysis and medical review—engage all aspects of health care. Our programs have worked directly with thousands of physicians and other health care providers across the United States, affecting millions of people from children to senior citizens.

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