Registered Nurse - Case Review Specialist - *Position is Remote/Nationwide

Ensure exam scheduling requests are submitted timely, and appointment notifications are tracked in accordance with the designated timeframe. 

Retrieve exams for case review processing (from the FOH clinics and the FOH Private Provider Network clinics). 

Enter in tickets for services performed at the FOH Private Provider Network (PPN) clinics. 

Process exams which include the QA of the exam, tracking any missing exam components, ensuring the exam is complete and has all components needed per the work order, and send the exam to the RMO for processing. 

Track exams and ensure exam processing is fluid and timely. 

Enter applicable data on RMO Timesheets. 

Ensure medical reviews, letters, and exams are sent securely as applicable. 

Enter tickets to charge the associated agency for the AMA/RMO time. 

Participate in cost recovery efforts which will include verifying/validating, editing, and updating billing tickets as needed. 

Professionally communicate with fellow team members, internal, and external customers. 

Ensure case review processing timeframes and quality assurance parameters are met as directed by the Program Manager (PM) before cases are forwarded to an RMO for review and/or to the agency. 

Attend all mandatory meetings and trainings as assigned. 

Demonstrate understanding of the Case Review process, work to learn new workflows and processes. 

Display competencies in all areas of case review. 

Ensure scheduling requests are submitted within 24 hours of receipt to the appropriate OHC or through the Private Network Provider (PPN). 

Ensure medical records are retrieved using the PPN portal daily and the internal electronic file storage.  

Reach out to OHC clinic to request records after exam completion. Follow up on any missing exam items timely and track to ensure requested item has been received, is complete, and is entered in tracking system. 

Ensure exams are processed timely to meet the requirements of FOH. Upon receiving a complete exam, QA, send to the RMO (if applicable), complete data entry/tracking, and send RMO determination to agency. 

Escalate missing exam items to PM when items are not received. 

Transmit exams according to IAA specifics and dates tracked. 

Report all privacy and security breaches immediately according to FOH and HHS policy. 

Attend all meetings with team and internal customers as directed. 

Coordinate with Business Operations team to provide customer services (e.g., exams, outreach, etc.) through FOH OHCs and the PPN. 

Assist with implementing new case review business and changing requirements for existing business when new agreements are initiated or if an existing agreement is modified. 

Ensure RMO and admin billing is completed, review any discrepancies, and notify PM. 

Review PPN invoices each month, identify discrepancies, and correct billing as needed. 

Ensure all billing items have been entered correctly and timely, concurrently when reviewing exams. 

Demonstrate a complete understanding of the current database used for billing, RMO reviews and exam tracking. 

Participate in rolling audits by analyzing reports, validating charges, and ensuring any missing charges are entered or discrepancies rectified timely. 

Be on time to work and work all designated hours as determined by PM. 

Request leave according to specified timeframes with vendor and PM. 

Adhere to telework policy when permitted. 

Create a climate of trust, accountability, and professionalism. Report to PM staffing concerns which can affect productivity and morale. 

Identify and report problems with hardware, telecommunications or other issues impacting duties to PM. 

Fully knowledgeable and proficient in IT systems, for database tracking, billing, and other deliverables, to include but not limited to Microsoft Word, Excel, Outlook, Teams and Adobe Acrobat. 

Attends training on IT systems and completes mandatory IT training by specified deadlines. 

Inform PM of IT and other equipment needs, particularly those that prevent completion of case review processing within specified deadlines. 

Performs all FOH associated tasks on Government Furnished Equipment. 

Manage customer/agency complaints professionally with feedback within 24-48 hours of receipt. If unable to resolve the complaint, communicate with customer this issue is being addressed and follow up as soon as possible, including PM. For urgent matters, notify PM immediately. 

Ensure exam processing timeline is met per the agency agreement. 

Communicate with RMO’s when a specific/urgent request is needed. 

Generate customer specific reports as required per the agency agreement. 

Input data into tracking sheets to retrieve metrics as requested by leadership. 

Suggest process improvements to PM to ensure that quality and efficiency goals for the case review team are met. 

Ensure data is entered completely for case review processing into database and onto agency specific trackers to include the exam scheduling tracker and exam tracker. 

Must possess full, active, current and unrestricted licensure as a licensed Registered Nurse in a State, Territory or Commonwealth of the United Sates, or the District of Columbia. 

Must be a graduate of an accredited school of nursing. BSN degree is recommended, but not required. AA degree is acceptable. 

Current CPR/AED for Health Care Professionals certification