Professional Review Nurse - Clinical Medical Auditor - Remote in California - Workers' Compensation and Healthcare Risk Management

Join the CorVel Team as a Professional Review Nurse - Clinical Medical Auditor

CorVel, a renowned leader in risk management solutions for workers' compensation, auto, health, and disability management industries, is seeking a highly skilled and experienced Professional Review Nurse - Clinical Medical Auditor to join our dynamic team. As a key member of our Clinical Review team, you will play a crucial role in analyzing medical services to determine the appropriateness of charges and reviewing medical reports to ensure the quality of medical care. This is a unique opportunity to utilize your clinical expertise and technical skills to make a positive impact on the delivery of healthcare services and the management of workers' compensation claims.

About CorVel

CorVel is a national provider of industry-leading risk management solutions, founded in 1987 and publicly traded on the NASDAQ stock exchange since 1991. We are a certified Great Place to Work® Company, committed to delivering innovative and integrated solutions to our clients. With over 4,000 employees working across the United States, we pride ourselves on our core values of Accountability, Commitment, Excellence, Integrity, and Teamwork (ACE-IT!). Our company culture is built on a foundation of respect, empathy, and collaboration, providing a supportive and inclusive work environment that fosters growth and development.

Job Summary

As a Professional Review Nurse - Clinical Medical Auditor, you will be responsible for conducting thorough reviews of medical bills and reports to ensure the accuracy and appropriateness of medical charges and services. You will utilize your clinical expertise and technical skills to identify errors, discrepancies, and potential fraudulent activities, and communicate your findings to claims examiners, clients, and other stakeholders. This is a remote role, and you must reside in California.

Key Responsibilities

• Analyze medical services to determine the appropriateness of charges and review medical reports to ensure the quality of medical care
• Identify errors, discrepancies, and potential fraudulent activities, including duplicate billing, unbundling of charges, services not rendered, mathematical and data entry errors, and other billing irregularities
• Collect supporting data and analyze information to make decisions regarding the appropriateness of billing, delivery of care, and treatment plans
• Communicate findings and recommendations to claims examiners, clients, and other stakeholders
• Document work and final conclusions in a designated computer program
• Adhere to regular and consistent work attendance and comply with all safety rules and regulations
• Respond to additional job duties as assigned by management or determined by legislative changes and/or market changes

Essential Functions and Responsibilities

Clinical and Technical Expertise

• Utilize clinical and technical expertise to address the provision of medical care and identify errors and discrepancies in billing practices
• Apply knowledge of medical terminology, anatomy, and physiology to analyze medical reports and bills
• Stay up-to-date with changing regulations, laws, and industry standards related to workers' compensation and healthcare

Communication and Interpersonal Skills

• Communicate concisely and effectively in writing and verbally with claims examiners, clients, attorneys, physicians, and other stakeholders
• Interface with claims adjusters, attorneys, physicians, and their representatives, and advisors/clients, and co-workers
• Promote Professional Review products and services to attorneys, claims examiners, customers, and management
• Negotiate provider fees effectively

Documentation and Record-Keeping

• Completely document work and final conclusions in a designated computer program
• Maintain accurate and detailed records of reviews and findings

Requirements and Qualifications

Education and Experience

• Current licensure as a Registered Nurse in the state of California
• Minimum of 4 years of clinical experience
• Associate Degree in Nursing or higher
• Thorough knowledge of CPT and ICD-10 codes
• Medical bill auditing experience preferred
• Experience in clinical areas such as OR, ICU, CCU, ER, and orthopedics preferred
• Prospective, concurrent, and retrospective utilization review experience preferred

Skills and Competencies

• Strong analytical and critical thinking skills
• Excellent communication and interpersonal skills
• Ability to work independently and as part of a team
• Strong attention to detail and organizational skills
• Computer literacy and proficiency in Microsoft Office and other software applications

Career Growth Opportunities and Learning Benefits

At CorVel, we are committed to the growth and development of our employees. We offer a range of career advancement opportunities, including:

• Professional development and training programs
• Career progression and promotion opportunities
• Mentorship and coaching
• Industry conferences and workshops

Work Environment and Company Culture

CorVel is a remote-friendly company, and this role can be performed from the comfort of your own home. We offer a comprehensive benefits package, including:

• Medical, dental, and vision insurance
• Long-term disability insurance
• Health savings account and flexible spending account options
• Life insurance and accident insurance
• Critical illness insurance and pre-paid legal insurance
• 401(k) and Roth 401(k) retirement plans
• Paid time off and holidays

Compensation and Benefits

Our compensation package is designed to attract and retain top talent. The pay range for this role is:

• $68,640 - $83,551 per year

We also offer a comprehensive benefits package, as outlined above.

Why Join CorVel?

At CorVel, we are passionate about delivering innovative and integrated solutions to our clients. We are committed to our core values of Accountability, Commitment, Excellence, Integrity, and Teamwork (ACE-IT!). By joining our team, you will have the opportunity to:

• Make a positive impact on the delivery of healthcare services and the management of workers' compensation claims
• Utilize your clinical expertise and technical skills to drive results
• Grow and develop your career in a supportive and inclusive work environment
• Enjoy a comprehensive benefits package and competitive compensation

How to Apply

If you are a motivated and experienced healthcare professional looking for a new challenge, we encourage you to apply for this exciting opportunity. Please submit your application, including your resume and cover letter, to [insert contact information]. We look forward to hearing from you!