Branch Review Specialist conducts branch internal audits to determine whether business controls are sufficient and effectively executed in accordance with bank policies and procedures. Tests established procedures to ensure operational efficiency within branch offices. Being a Branch Review Specialist determines whether branches are performing their planning, accounting, custodial, or business control activities in compliance with management instructions, policies, and procedures. Evaluates functions and activities in assigned areas to determine the nature of operations and the adequacy of systems to achieve established objectives. Additionally, Branch Review Specialist recommends corrective actions and improvements. Requires a bachelor's degree. Typically reports to a supervisor or manager. The Branch Review Specialist occasionally directed in several aspects of the work. Gaining exposure to some of the complex tasks within the job function. To be a Branch Review Specialist typically requires 2 -4 years of related experience. (Copyright 2024 Salary.com)
SCOPE OF POSITION:
Responsible for analyzing patient records to determine legitimacy and necessity of medical services in compliance with government reimbursement policies. Review may be prior authorization, concurrent with service or post service. Review findings may be referred to a physician advisor for final determination. Support the organization’s mission, vision, and values by exhibiting the following behaviors: Honesty, Excellence Accountability, Respect and Teamwork.
ESSENTIAL JOB FUNCTIONS:
Review each selected record accurately and according to AFMC, state and federal policies and procedures.
Function as a resource for non-clinical staff by providing oversight and follow-up for clinical related questions or issues
Write effective and accurate review summaries and submit within appropriate time frame.
Refer all cases that do not meet established medical necessity criteria for approval to a peer clinical reviewer on a daily basis.
Maintain files for recording and reporting in accordance with established procedures.
Perform site surveys as required or directed if relevant to your department. Must be able to travel within the State as needed to accomplish required site visits if relevant to your department.
Prepare monthly reports and/or statistics as directed.
Communicate effectively with internal and external clients. Upon request, verbally informs patients, facility personnel, the attending physician and other ordering providers, and health professionals of specific utilization management requirements and procedures
Seek direction from Review Manager, Clinical Director, Associate Medical Director, or VP Chief Medical Officer for any clinical related questions or issues during the review process.
Daily quotas may be added to meet contract deliverables as needed.
Adhere to format, content and style guidelines, giving consideration to usability and ensuring accuracy, consistency, and quality.
Follow AFMC, state and federal protocols regarding data confidentiality/security and HIPAA compliance.
Additional duties as assigned.
KNOWLEDGE, SKILLS AND ABILITIES:
Physical and Sensory Requirements (With or Without the Aid of Mechanical Devices):
Mobility, reaching, bending, lifting, grasping, ability to read and write, ability to communicate with personnel, ability to remain calm under stress and ability to travel as needed. Must be able to lift and transport 25 pounds. Must be capable of performing the essential job functions of this job, with or without reasonable accommodations.
EDUCATION:
Required: Diploma or Associate’s degree in nursing, licensed as a Registered Nurse in the state of Arkansas without restrictions or licensed as a multistate Registered Nurse and can practice in the state of Arkansas.
Desirable: Bachelor’s degree in nursing
EXPERIENCE:
Required: Three (3) years clinical nursing experience
Desirable: Quality Assurance / Utilization Review and/or coding experience, QIO experience
INTERNET REQUIREMENTS:
Reliable, high-speed wireless internet service (Wi-Fi)