Job Details

**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 experienceshould 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

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c)