Professional Healthcare Solutions

06/08/2024

Hiring! Registered Nurses with two years experience. Position: Medical Review Claims Analyst to review claims for Medicare fraud, waste and abuse. Full-time, Remote position. Monday thru Friday. Message me for more specifics.

01/20/2022

Position Overview:

The position requires the Registered Nurse to conduct medical record reviews and to apply sound clinical judgment to claim payment decisions. Responsibilities may include additional research on medical claims data and other sources of information to identify problems and utilize a variety of tools to detect situations of potential fraud and to support the ongoing fraud investigations and requests for information. The Registered Nurse will work with PHS leadership, in concert with our clients, to review cases and produce a concise and accurate summary of determinations. The Registered Nurse will comply with the PHS policies related to Conflict of Interest and Compliance and will abide by the PHS Code of Conduct.

Prerequisite:

Current Oklahoma Registered Nursing license and not listed on the OIG Excluded Individual database
Two years of experience in the medical field as a Registered Nurse. May substitute one year of clinical experience for experience in review of medical claims for coverage and medical necessity
Demonstrated history of professional conduct and success in working independently and as a member of a team
Strong interpersonal skills
Strong critical thinking and investigative skills
Strong verbal and written communication and organization skills
Strong computer knowledge and skills, including Microsoft Word and Excel programs

Essential Functions:

Ability to present issues of concern, citing regulatory violations, alleging schemes or scams to defraud the Government·
Ability to gather information systematically in order to establish facts
Ability to research regulations and cite violations
Ability to conduct self-directed research to uncover problems in Medicare payments made to institutional and non-institutional providers
Ability to make claim payment decisions based on clinical knowledge
Ability to compose medical review summary reports and correspondence concisely and accurately
Ability to communicate effectively, internally and externally
Ability to handle PHI and ePHI in a secure and confidential manner
Ability to report work activity on a timely basis
Ability to work independently and as a member of a team to deliver high quality work
Ability to attend meetings and education offerings.
Ability to manage time effectively, prioritizing tasks and able to meet deadlines

02/19/2020

Professional Healthcare Solutions is currently hiring for full time medical review analysts. Please contact us if you are interested.

12/28/2018

The family at Professional Healthcare Solutions is saddened to report that one of our own has passed away. David Bryan passed away on 12/27/2018 after a brief battle with cancer. He was a beloved member of the PHS family and he will be missed by all! Our prayers are with his family during this time of loss!!!

10/18/2016

The nation’s largest nursing home pharmacy, Omnicare Inc., has agreed to pay $28.125 million to resolve allegations that it solicited and received kickbacks from pharmaceutical manufacturer Abbott Laboratories in exchange for promoting the prescription drug, Depakote, for nursing home patients.  CVS...

09/09/2016

07/26/2016

Three Miami-area health care providers were charged in an elaborate and long-running fraud scheme that resulted in more than $1 billion in losses.

07/13/2016

NEWARK, NJ—A Rockaway, New Jersey, husband and wife who owned a mobile diagnostic testing company today admitted receiving more than $4.3 million from Medicare and private insurance companies for diagnostic testing and reports that were never interpreted by a licensed physician, U.S. Attorney Paul J...