Rising Medical Solutions

Auditor

• Audit medical and billing records to determine if services provided are reasonable, appropriate and necessary.
• Clinically identify and evaluate any charges not related to the occurrence.
• Verify that charges are in accordance with the services ordered and authorized.
• Initiate appropriate contacts with clients and medical providers as appropriate and necessary.
• Negotiate bills and conduct re-evaluation reviews as required
• All while maintaining a human touch, demonstrating sensitivity to culturally-diverse people and situations.

Nurse Auditor - Medical Bill Review

Systems Engineer

• Translate business requirements into technical requirements and ensure all system requirements adequately reflect defined business processes and fully support all components of the functional business requirements
• Communicate requirements and collaborate with developers, QA analysts, and other project team members to implement or enhance systems
• Represent Rising in client and partner meetings for system implementations
• Develop a subject matter expertise on one or more aspects of integrations between company and external systems and/or internal systems
• Assist with production support - investigate issues, root cause analysis, report and communicate detailed findings when necessary
• Develop use cases and process/data flow diagrams
• Support the creation and/or create test plans and relevant training materials
• Conduct reviews of systems and identify enhancements that support company strategies and affect key performance indicators
• Conduct training for other Professional Services team members for subject matter knowledge transfers

Systems Analyst II

Administrative Assistant

• Manage and/or assign files to appropriate staff member and initiate appropriate verbal and/or written contacts with employers, clients, claimants, and medical providers.
• Set up files in all appropriate systems; assign files, when applicable, to the nurse.
• Maintain responsibility of an individual caseload.
• Maintain appropriate electronic and paper files.
• Interface with a variety of inter-disciplinary providers (e.g., PT, diagnostic, psychology, etc.).
• Identify, maintain, and update participating providers.
• Answer incoming calls, and direct the call appropriately.
• Process all documents using computer, copier, and scanner.
• Search and copy the appropriate internal criteria guidelines, when appropriate.
• Work as part of a team to meet turn-around time for the set activity.
• Keep supervisor advised of any problems or delays.
• Continually improve job skills and knowledge of all company products and services as well as customer issues and needs, through ongoing training and self-directed research.
• Adhere to company policies, procedures, and reporting requirements.

Medical Administrative Assistant

Attorney

• Evaluate liability demand packages, including medical records, billing, and treatment timelines to identify gaps, inconsistencies, and cost drivers
• Utilize evidence-based guidelines (ODG, MCG, InterQual, etc.) to determine authorization versus escalation to Peer or Physician Review
• Review and analyze past and projected cost of medical treatment.
• Document appropriately in Rising’s systems (and client systems as needed), and issue demand package review report
• Write clear, concise, and defensible nurse summaries on all UR and demand review files.
• Establish and maintain collaborative relationships with clients, attorneys, and internal stakeholders

Lead Legal Nurse

• Evaluating liability demand packages, including medical records, billing, and treatment timelines to identify gaps, inconsistencies, and cost drivers
• Utilizing evidence-based guidelines (ODG, MCG, InterQual, etc.) to determine authorization versus escalation to Peer or Physician Review
• Reviewing and analyzing past and projected cost of medical treatment.
• Documenting appropriately in Rising’s systems (and client systems as needed), and issuing demand package review report
• Writing clear, concise, and defensible nurse summaries on all UR and demand review files.
• Establishing and maintaining collaborative relationships with clients, attorneys, and internal stakeholders