Clinical Nurse Reviewer

About the Company:

Avalon Healthcare Solutions, headquartered in Tampa, Florida, is a clinical services and information technology company using evidence-based medicine to develop and deploy medical policies and protocols in the high-volume, dynamic and complex diagnostic lab environment. The company manages the appropriate use of thousands of existing lab tests and researches new tests to determine efficacy and impact on patient care.

Studies show that 30% of clinical laboratory testing is unnecessary or overused. Inappropriate testing or missing a key screening can lead to complications and expense arising from unwarranted care, or not obtaining proper care when needed, leading to increased health risks and costs. Avalon helps ensure delivery of the right test, at the right time, and in the right setting. We seek to ensure the most effective patient treatment, improve clinical outcomes, and optimize cost and affordability.

Avalon is a portfolio company of Francisco Partners, a global private equity firm that specializes in investments in technology and technology-enabledservice companies. Since its launch 15 years ago, FP has raised approximately $10 billion and invested in more than 150 companies.

Avalon is a high growth company where every associate has an opportunity to make a difference. You will be part of a team that shapes a new market and business. You’ll enjoy seeing the results of your work as we rapidly implement our plan. Most importantly, you will help Avalon to achieve its mission and improve clinical outcomes and health care affordability for the people we serve.

For more about Avalon, please visit our web site at http://www.avalonhcs.com.

This position is eligible for remote telework to cover 1pm – 10pm ET shift.

About the Nurse Reviewer Position:

The Nurse Reviewer applies health plan medical policies and criteria to establish medical necessity.

Nurse Reviewer Essential Functions and Responsibilities:

  • Reviews preservice laboratory testing services requests to establish medical necessity
  • Provides support to front-line staff and internal customers
  • Documents request details for Physician Reviewers
  • Makes outbound calls to providers to request additional clinical information
  • Assesses the appropriateness of submitted procedure codes (e.g., correct coding)
  • Interacts with internal physicians and external providers to ensure accuracy of billing codes
  • Demonstrates the ability to handle multiple lines of business
  • Other duties as assigned

Nurse Reviewer – Qualifications:

  • Two to three (2-3) years’ experience performing Preservice Review in a health plan.
  • Bachelor’s Degree or equivalent experience
  • Registered Nurse (RN) or Licensed Practical Nurse (LPN)
  • Ability to apply clinical judgment where appropriate.
  • Understanding of ICD-10-CM, CPT and HCPCS coding.

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