text: Medicare Set Aside Allocator: Sr Medicare Compliance Nurse RN - Baton Rouge, LA
  Medicare Set Aside Allocator: Sr Medicare Compliance Nurse RN
  Job Reference #: J3R6CK75453HZSRJTXT
  Sr Medicare Compliance Nurse
  Sedgwick's Medicare compliance team assists clients with Medicare Set-Asides (MSAs) and Medicare liens, which can impact workers' compensation and general, professional and auto liability claims. MSAs are reports created with the purpose of protecting Medicare's future interest in the event of a settlement. Our examiners use MSAs to negotiate settlements and the amount should provide funds for the claimant to treat their injury post settlement. We also assist with Medicare liens, which include any payments made by Medicare for the benefit of a claimant/plaintiff between the injury date and the settlement date. Our team reviews the liens for accuracy and handles any necessary negotiations to reduce them prior to settlement.
  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.
  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 guide lines 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.
  Assess, identify and document 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.