Clinical Quality Assurance Nurse Auditor (33135)

MES Solutions; Winslows (MA); Remote; USD 85,000 - 120,000; Full time

Benefits offered by this job

Medical, vision, dental benefits

Paid time off

401k

Job summary

MES Solutions seeks a self-driven, high-performing RN or LPN to join our team as Clinical Quality Assurance Nurse Auditor. You will evaluate clinical information, generate reports, and ensure compliance with client contracts and regulations.

This 100% remote role offers a steady daytime schedule (EST) and the chance to impact quality across cases. You will review medical records, author rationales with citations, resolve inconsistencies, and assist in addressing customer concerns.

Qualifications

• Bachelor/Associate degree in nursing or related field or equivalent experience.
• Experience with medical terminology, medications, medical specialties and treatment protocols.
• Experience in the insurance industry preferred.

Responsibilities

• Evaluate clinical information received, write and/or review reports including 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 client instructions and specifications are followed and all questions addressed.
• Ensure each review is supported by clinical citations and references from reputable journals.
• Ensure content, format, and professional appearance of reports meet company standards.
• Verify appropriate board specialty reviewed the case and documented on the report.
• Verify reviewer attested to facts and no conflict of interest exists.
• Ensure provider credentials and signature are adhered to in final report.
• Identify inconsistencies and contact the Reviewer to obtain clarifications.
• Assist in resolution of customer complaints and quality assurance issues.
• Ensure all federal ERISA or state mandates are adhered to.
• Provide insight on consultant quality, availability and compliance with policies.
• Promote efficient utilization of company resources.
• Participate in continuing education and training activities.
• Perform other duties as assigned.

Skills

Medical terminology & protocols

Education

Bachelor/Associate nursing or related field

Tools

Microsoft Word, Outlook, Excel, Internet

Job description

MES is looking for a is looking for a self-driven, high-performing RN or LPN to join our dynamic team as a Clinical Quality Assurance Nurse Auditor

The Clinical Quality Assurance Nurse Auditor is responsible for evaluating clinical information received from various healthcare providers and writes 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: 7:00am-3:30pm EST or 8:00am-4:30pm EST

• 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.

Qualifications

• 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, Licences, Registrations

• Must hold and maintain an unencumbered Registered Nursing licence
• Must have strong knowledge of medical terminology, anatomy and physiology, treatment protocols, medications and laboratory values
• 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.
• Must be able to demonstrate and promote a positive team -oriented environment.
• Must be able to stay focused and concentrate with frequent interruptions.
• Must be able to work well under pressure and or stressful conditions.
• Must possess the ability to manage change, delays, or unexpected events appropriately.
• Demonstrates reliability and abides by the company attendance policy.
• Must maintain a professional and clean appearance at all times consistent with company standards.

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.