Position Description: Quality Assurance Review NurseReporting to the Director, the QA Review Nurse will provide professional assessment, planning, coordination, implementation and reporting of complex clinical data and support the medical review operations of Provider Resources, Inc. (PRI). The nurse position will perform comprehensive medical record to make utilization, quality of care, and standards of care determinations based on evidence-based standards of care, applicable coverage policies, and utilization and practice guidelines.Responsibilities
Understand and represent PRI's mission, vision, and values to all internal and external customers
Interact with government and private sector clients, partners, and PRI staff in a professional and accountable manner, and as a representative of PRI management
Engage clients in appropriate communication that manages client expectations and builds a collaborative relationship with the client
Develops and maintains a detailed project schedule which includes administrative tasks involved in the project
Proactively manages and coordinates activities to ensure timeliness of deliverables to exceed contractual obligations
Interact with project team members in order to successfully fulfill contract obligations with the highest quality and in a timely manner meeting PRITM 's ISO requirements
Instills integrity throughout the organization via active participation in ISO requirements including but not limited to timely submission of Corrective Action Plans for all matters in which either PRITM standards and/or corporate contract standards have not been met. Communicating outcomes to team members to ensure a positive, open, environment which mitigates risk and achieves a culture of Continuous Quality Improvement
Screen cases upon intake for referral to peer reviewers
Perform medical record review in accordance with all State, Federal and/or commercially mandated regulations
Performs QA for non-physician reviews and supports PM
Maintain compliance with all regulation changes as they impact medical and utilization review practices
Analyze patient records and participate in interdisciplinary collaboration with PRI staff and all recognized teaming partners and/or subcontractors
Document all review information into the appropriate Medical Review form, report and/or system. Communicate these report results to the appropriate supervisor
Utilize electronic health information imaging
Utilize Internet and Intranet resources for applicable research, e.g., evidence-based standards of care guidelines, quality measures, etc.
Make clinical judgments based on evidence-based standards of care, review criteria and nursing practice guidelines when applicable
Understand and represent PRI's mission, vision, and values to all internal and external customers
Perform other duties as requested
Requirements:
Bachelor's Degree in Nursing (BSN), MSN preferred
Require a minimum of three (3) years' experience in a supervisory/managerial role in the health insurance industry
Extensive experience performing medical review, utilization/quality assurance reviews, and application of nursing standards of care
Must be a Registered Nurse (RN) with an active license in state of residence
Broad knowledge base of health care delivery and case management within a managed care environment
Knowledge of utilization review process, OIG, CMS, RAC, and all other regulatory agencies related to utilization management.
Comprehensive knowledge of medical necessity standards, levels of care, inpatient and outpatient status
Extensive knowledge of state and federal healthcare regulations and policies,
Two or more years' experience in medical/utilization review and quality i provement/quality management
Excellent writing and communication skills
Knowledgeable of quality measures and National Quality Strategy
Knowledgeable of ICD-9-CM/ICD-10-CM, CPT-4 and HCPCS coding desirable
Knowledge of Microsoft office suite such as Outlook, Access, Excel and Word
Certification in quality improvement/quality management, and/or utilization management/review preferred
One year or more of utilizing InterQual and/or Milliman guidelines is preferred
Must have no adverse actions pending or taken against him/her by any State or Federal licensing board or program
Must have no conflict of interest (COI) as defined in 1154(b)(1) of the Social Security Act (SSA)
Ability to obtain and maintain U.S. Government Security Clearance
Preference will be given to individuals who reside in, or are willing to relocate to, a recognized HUBZone area. (Go to http://map.sba.gov/hubzone/maps/ for more information).FLSA status: ExemptContract Compensation PlanPRI is an equal employment opportunity employer. All qualified applicants including Disability/Vets or other qualified applicants will receive consideration for employment without regard to race, color, religion, gender, national origin, disability status, protected veteran status or any other characteristic protected by law.Qualified candidates may apply by clicking, "Apply Now". Next, submit your resume. You may complete a cover letter on the following screen. You must contact the employer via one of the methods listed on the screen after clicking "Apply for this job". Please be sure to identify PA CareerLink as your referral source.