Nurse Reviewer

At Commence, we’re the start of a new age of data-centric transformation, elevating health outcomes and powering better, more efficient process to program and patient health. We combine quality data-driven solutions that fuel answers, technology that advances performance, and clinical expertise that builds trust to create a more efficient path to quality care. With human-centered, healthcare-relevant, and value-based solutions, we create new possibilities with data. We provide proof beyond the concept and performance beyond the scope with a focus on efficiencies that transform the lives of those we serve. With a culture driven by purpose, straightforward communication and clinical domain expertise, Commence cuts straight to better care.

The Nurse Reviewer position is responsible for supporting and conducting reviews and determinations for independent dispute resolutions at both the Federal and State levels. This role involves analyzing medical records, ensuring proper documentation, and providing quality assurance checks to support the final determination. IDRE Nurse Reviewers must ensure that their decisions are well-supported with robust rationale and comply with Federal or State guidelines. This position will be responsible for resolving claim disputes submitted by various parties, such as physicians, hospitals, institutions, pharmacies, and other licensed healthcare providers. Additionally, responsibilities will include resolving disputes submitted to the Federal Independent Review (IDR) process. IDRs conduct impartial reviews of healthcare services to resolve disputes between healthcare providers. facilities and payers. IDRs provide objective assessments of billing, coding, and other issues related to disputed claims. The role requires conducting all job duties efficiently, promptly, productively, consistently, and courteously while maintaining a high level of professionalism.

Conduct an initial assessment of documentation from both the initiating and responding parties. Review submitted documentation to identify missing documents and determine what is required to resolve the dispute. Follow procedures to obtain the appropriate documentation. Determine the appropriate type of clinical reviewer necessary to complete the case, such as a medical coder or a physician. Prepare documents for the arbitrator reviewer assigned and provide instructions as needed. Collaborate with the legal team to facilitate resolution of disputes. Draft professional determination correspondence. Perform quality assurance checks on determinations according to Federal or State guidance. Audit and analyze patient records to ensure appropriate determination. Stay current with regulation changes and perform research on a case-by-case basis. Deliver high-quality, professional determinations free of grammar and spelling errors. Amend reports with additional clinical information when necessary. Participate in an interdisciplinary health care team to achieve positive outcomes.