Clinical Quality Assurance Nurse Auditor

MES Solutions; United States; Remote; USD 35,000 - 132,000; Full time

Job summary

Join a leading company as a Clinical Quality Assurance Nurse Auditor. This remote role involves evaluating clinical information and ensuring compliance with healthcare standards. With competitive benefits, it's an opportunity for registered nurses looking to leverage their skills in a dynamic and supportive environment. The position offers work-life balance while contributing to meaningful healthcare assessments.

Benefits

Medical benefits

Dental benefits

Vision benefits

401k plan

Paid time off

Qualifications

• Bachelor's or Associate degree in nursing with at least 5 years experience.
• Experience in the insurance industry is preferred.
• Must possess strong knowledge of medical terminology and practices.

Responsibilities

• Evaluate clinical information and write reports for quality assurance.
• Ensure compliance with client specifications and regulatory standards.
• Handle quality assurance questions and support the Quality Assurance Department.

Skills

Communication

Attention to Detail

Medical Terminology Knowledge

Time Management

Independent Work

Education

Bachelor's Degree in Nursing

RN License

Tools

Microsoft Word

Microsoft Excel

Healthcare Software

Job description

Clinical Quality Assurance Nurse Auditor

Join to apply for the Clinical Quality Assurance Nurse Auditor role at MES Solutions

Clinical Quality Assurance Nurse Auditor

Join to apply for the Clinical Quality Assurance Nurse Auditor role at MES Solutions

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Description

Calling all Registered Nurses from Across the U.S.

Description

Calling all Registered Nurses from Across the U.S.

Are you looking for a position that is challenging, will keep your clinical skills sharp, but doing so from the comfort of home?

MES is seeking a self-motivated, high-performing registered nurse (RN) to join our team.

The Clinical Quality Assurance Nurse Auditor is responsible for evaluating clinical information received from various healthcare providers and writing reports based on clinical information received. This position ensures reports are completed with highest quality and integrity and that all work is in full compliance with client contractual agreements, regulatory agency standards and federal and state mandates. This position is required to handle quality assurance questions and provide overall support to the Quality Assurance Department.

The position is 100% remote with a schedule of Monday through Friday, 9:00am-5:30pm EST (with some flexibility on start and end times).

Duties And Responsibilities

• Evaluate clinical information received, write and/or review various reports including, but not limited to, Medical Record Reviews, Medical Record Chronologies, Provider Bill Reviews, Coding Reviews, Hospital Bill Reviews, List of Missing Records, Medical Bill Apportionments, Mock Billing Invoice and Medical Summary Statements.
• Perform quality assurance review of peer review reports, correspondences, addendums or supplemental reviews.
• Ensure clear, concise, evidence-based rationales have been provided in support of all recommendations and/or determinations.
• Ensure that all client instructions and specifications have been followed and that all questions have been addressed.
• Ensure each review is supported by clinical citations and references when applicable and verify that all references cited are current and obtained from reputable medical journals and/or publications.
• Ensure the content, format, and professional appearance of the reports are of the highest quality and in compliance with company standards.
• Ensure the appropriate board specialty has reviewed the case in compliance with client specifications and/or state mandates and is documented accurately on the case report.
• Verify that the reviewer has attested to only the facts and that no evidence of reviewer conflict of interest exists.
• Ensure the provider credentials and signature are adhered to the final report.
• Identify any inconsistencies within the report and contacts the Reviewer to obtain clarification, modification or correction as needed.
• Contact the appropriate person to recover any missing documentation or verify charges.
• Assist in resolution of customer complaints and quality assurance issues as needed.
• Ensure all federal ERISA or state mandates are adhered to at all times.
• Provide insight and direction to management on consultant quality, availability and compliance with all company policies and procedures and client specifications.
• Promote effective and efficient utilization of company resources.
• Participate in various continuing education requirements and or training activities.
• Perform other duties as assigned.
  
  

If you're ready for a new challenge and want to thrive in a role that offers work-life balance, read on!

Qualifications

Education and/or Experience

Bachelor/Associate degree in nursing or related field; or minimum five years related experience; or equivalent combination of education and experience. Experience with medical terminology, medications, medical specialties and treatment protocols required. Experience in the insurance industry preferred.

Certificates, Licenses, Registrations

RN/LPN license

• Must have strong knowledge of medical terminology, anatomy and physiology, medications and laboratory values.
• Must be able to add, subtract, multiply, and divide in all units of measure, using whole numbers and decimals; Ability to compute rates and percentages.
• Must be a qualified typist with a minimum of 40 W.P.M
• Must be able to operate a general computer, fax, copier, scanner, and telephone.
• Must be knowledgeable of multiple software programs, including but not limited to Microsoft Word, Outlook, Excel, and the Internet.
• Must possess excellent skills in English usage, grammar, punctuation and style.
• Ability to follow instructions and respond to upper managements’ directions accurately.
• Demonstrates accuracy and thoroughness. Looks for ways to improve and promote quality and monitors own work to ensure quality is met.
• Must demonstrate exceptional communication skills by conveying necessary information accurately, listening effectively and asking questions where clarification is needed.
• Must be able to work independently, prioritize work activities and use time efficiently.
• Must be able to maintain confidentiality.
  
  

MES Solutions is a premier provider of independent medical examination and peer review services to the insurance, corporate, legal, and government sectors. Members of our credentialed medical panel conduct physical examinations or medical record reviews, delivering reports that assist clients in the resolution of automotive, disability, liability, and workers' compensation claims. MES has been providing services nationally since 1978 in accordance with the industry's highest standards of operating excellence and regulatory compliance.

MES offers a fast-paced team atmosphere with competitive benefits (medical, vision, dental), paid time off, and 401k.

Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, pregnancy, genetic information, disability, status as a protected veteran, or any other protected category under applicable federal, state, and local laws.

Seniority level

• Seniority level

  Mid-Senior level

Employment type

• Employment type

  Full-time

Job function

• Job function

  Quality Assurance

• Industries

  Insurance

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