RN Medicare Compliance

Taking care of people is at the heart of everything we do, and we start by taking care of you, our valued colleague. A career at Sedgwick means experiencing our culture of caring. It means having flexibility and time for all the things that are important to you. It’s an opportunity to do something meaningful, each and every day. It’s having support for your mental, physical, financial and professional needs. It means sharpening your skills and growing your career. And it means working in an environment that celebrates diversity and is fair and inclusive. 

A career at Sedgwick is where passion meets purpose to make a positive impact on the world through the people and organizations we serve. If you are someone who is driven to make a difference, who enjoys a challenge and above all, if you’re someone who cares, there’s a place for you here. Join us and contribute to Sedgwick being a great place to work.

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RN Medicare Compliance

PRIMARY PURPOSE:  To provide professional assessment, planning, coordination, implementation, and reporting of complex clinical data; to complete complex submissions revisions/updates in preparation for Medicare review and act as an internal resource regarding Centers for Medicare & Medicaid Services (CMS) guidelines.

ESSENTIAL FUNCTIONS and RESPONSIBILITIES

• Prepares and drafts complex Medicare Set-Asides (MSAs), Medical Cost Projects (MCPs), Submission cases, and related products; completes MCPs in preparation for reserve setting or settlement.

• Performs comprehensive medical record reviews and evaluates Workers’ Compensation Medicare Set-Aside proposals to make recommendation to Centers for Medicare & Medicaid Services (CMS) for final determination based on applicable coverage policies, coding guidelines and utilization and practice guidelines.

• Reviews medical claims and completes complex file review for Medicare Set- Asides (MSA) and future medical cost projections.

• Serves as a consultant to Medicare Compliance Nurses on claims.

• Applies clinical knowledge and expertise with established clinical guidelines and provide clients with accurate and timely reviews of clinical referrals and a comprehensive analysis of medical treatment.

• Assists with providing required training to examiners handling medical/Medicare issues related to general liability and workers’ compensation and mentors less experienced colleagues.

• Executes clear, concise, and thorough medical record summary narratives for the purpose of inclusion in a Medicare Set-Aside or Future Medical Cost Projection.

• Assesses, identifies, and documents critical elements potentially impacting MSA cost projections for possible reduction and impact of any treatment guidelines and offers input to resolve issues.

• Records and completes documentation of the findings and analysis of medical records.

• Utilizes claims, legal, and/or nursing knowledge to analyze medical records and identify future medical treatment as documented in the medical records.

• Utilizes resource data bases for diagnoses, treatment guidelines, and prescription medication pricing, documenting the MSA allocation when applicable and finalizes the MSA allocation including cost projections.

ADDITIONAL FUNCTIONS and RESPONSIBILITIES

• Performs other duties as assigned.

• Travels as required.

QUALIFICATIONS

Education & Licensing

Bachelor's degree or equivalent from an accredited college or university preferred.  Active unrestricted RN license issued in a state or territory of the United States required.  Medicare Set-Aside Consultant Certified (MSCC) certification required or actively enrolled in the MSCC certification program and must be completed within 60 days of hire.

Experience

Six (6) years of related experience to include five (5) years of MSA writing experience or equivalent combination of education and experience required.

Skills & Knowledge

• Thorough knowledge of MSA creation and pricing

• Proficiency in medical research online and in written text

• Excellent oral and written communication skills

• PC literate, including Microsoft Office products

• Excellent mathematical skills

• Analytical and interpretive skills

• Strong organizational skills

• Ability to work in a team environment

• Ability to meet or exceed Performance Competencies

WORK ENVIRONMENT

When applicable and appropriate, consideration will be given to reasonable accommodations.

Mental:  Clear and conceptual thinking ability; excellent judgment, troubleshooting, problem solving, analysis, and discretion; ability to handle work-related stress; ability to handle multiple priorities simultaneously; and ability to meet deadlines

Physical:  Computer keyboarding, travel as required

Auditory/Visual:  Hearing, vision and talking

NOTE:  Credit security clearance, confirmed via a background credit check, is required for this position.

The statements contained in this document are intended to describe the general nature and level of work being performed by a colleague assigned to this description.  They are not intended to constitute a comprehensive list of functions, duties, or local variances.  Management retains the discretion to add or to change the duties of the position at any time.

As required by law, Sedgwick provides a reasonable range of compensation for roles that may be hired in jurisdictions requiring pay transparency in job postings. Actual compensation is influenced by a wide range of factors including but not limited to skill set, level of experience, and cost of specific location. For the jurisdiction noted in this job posting only, the range of starting pay for this role is $78,000-$85,000. A comprehensive benefits package is offered including but not limited to, medical, dental, vision, 401k and matching, PTO, disability and life insurance, employee assistance, flexible spending or health savings account, and other additional voluntary benefits. 

Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace.

If you're excited about this role but your experience doesn't align perfectly with every qualification in the job description, consider applying for it anyway! Sedgwick is building a diverse, equitable, and inclusive workplace and recognizes that each person possesses a unique combination of skills, knowledge, and experience. You may be just the right candidate for this or other roles.