Clinical Quality Reviewer

USFHP; New York (NY); Híbrido; USD 80.000 - 115.000; Jornada completa

Descripción de la vacante

USFHP in Manhattan, NY is seeking a Clinical Quality Reviewer (hybrid) to oversee post-service clinical reviews across care settings. The role emphasizes adherence to standards of care, data-driven analysis, and timely issue resolution under the Quality Management department.

The ideal candidate holds an RN or LPN/LVN license with 1–3 years in quality management and strong MS Office skills. You will collaborate with internal teams and vendors to improve beneficiary services while maintaining

Formación

• RN or LPN/LVN license required.
• 1-3 years of healthcare quality management experience.
• Ability to read and abstract medical records and data.
• Strong analytical and problem-solving skills.
• Proficiency with Microsoft Office tools (Excel, Word, PowerPoint).

Responsabilidades

• Conduct post-service clinical reviews and document findings.
• Perform literature reviews and summarize findings.
• Contact providers to obtain medical records for reviews.
• Chart reviews and data abstraction for audits and investigations.
• Prepare concise investigative summaries and letters.
• Collaborate with stakeholders and maintain confidentiality.
• Meet deadlines and report quality issues promptly.

Conocimientos

Healthcare quality management

Nursing experience

Analytical skills

Communication skills

Data analysis

Educación

RN or LPN/LVN licensed

BA/BS or BSN preferred

Herramientas

Excel

Outlook

PowerPoint

Word

Access

Descripción del empleo

Title: Clinical Quality Reviewer
Department: Quality Management
Reports To: Team Lead
Location: Manhattan, NY – HYBRID
Education: RN or LPN/LVN Required
Job Type: Full Time, Exempt

Job Summary

Reports to Team Lead, Clinical Quality and Record Review. Works independently and with other departments and/or
vendors to ensure clinical potential quality issues are tracked, investigated and resolved in accordance with TRICARE
and Plan requirements. Primarily responsible for conducting post-service in-depth clinical reviews (all care settings) in
accordance with accepted standards of care. The overall goal is to improve clinical service delivery.

Responsibilities

Clinical Review

• Utilizes clinical expertise to conduct clinical case retrospective reviews to determine deviation from standard of care or gaps in care and presence of mandatory data elements. Document progress of investigation and findings in internal databases and/or Excel spreadsheets.
• Conduct clinical literature reviews and summarize findings.
• Contact providers/facilities, as applicable, to obtain information and/or medical records needed to conduct a comprehensive clinical review of cases and final determinations.
• Conduct chart reviews and audits both electronic and at medical facilities and providers’ offices. Abstract data relevant to review target.
• Write succinct and targeted investigative summaries. Write quality review determination letters.
• Develop and manage collaborative relationships with internal/external stakeholders and vendor staff.
• Maintain confidentiality of all medical records, correspondence and related documents.
• Effectively meets strict deadlines.
• Aware of the potential for fraud and waste and how to report suspected fraudulent activity.

Data Analysis and Reporting

• Participate in collection and analysis of data for clinical CDRLs reports (i.e., monthly quality issue report, AHRQ
• PSI report, annual clinical quality management program report).
• Participate in collection, analysis and presentation of data for Peer Review, Credentials Review and Quality

Continuous Quality Improvement

• Participate in continuous quality improvement activities/root cause analysis to resolve identified quality issues and ensure forward movement in beneficiary service delivery.
• Cross-train and perform other duties as assigned or required within the Quality Department. Attends meetings to achieve departmental/organizational goals and objectives.

Experience

• 1-3 years of healthcare quality management experience.
• 1-3 years of clinical nursing experience.
• Quality assurance/improvement experience in a managed health plan, integrated health care system, or health care accreditation or regulatory agency.
• Ability to read, abstract and analyze medical records as well as other clinical data.
• Analytical mindset with excellent organizational and problem-solving skills.
• Ability to work both independently and as a team member.
• Intermediate statistical analysis expertise including interpretation of data.
• Communications: Effective verbal and written communication skills. Able to work collaboratively with different teams and different team members. Ability to work both independently and as a team member.
• Manages assigned caseload in accordance with established performance metrics.
• Understanding of medical terminology, anatomy, physiology and concepts of disease and health. Fundamental knowledge of ICD-10, CPT and HCPCS coding.
• Understanding of Medicare, Medicaid and/or TRICARE.
• Proficient in Microsoft Office, including but not limited to Excel, Outlook, PowerPoint and Word. Experience in Access and Visio a plus. Ability and inclination to adopt technology to maximize efficiency.
• Decision making: Identification of clinical quality issues as evidenced by deviation from accepted standard of practice or gap in care. Ability to recommend corrective actions and/or sanctions.

Education/License/Certification

• Current and unrestricted state RN or LPN/LVN license required (CT, NJ, NY, PA)
• BA, BS, or BSN preferred

Salary Range: LPN/LVN $80,000 – $85,000.00 RN $107,000.00 – $115,000.00

SVCMC IS AN EQUAL OPPORTUNITY EMPLOYER – ALL QUALIFIED APPLICANTS WILL RECEIVE CONSIDERATION FOR EMPLOYMENT WITHOUT REGARD TO PROTECTED VETERAN STATUS, DISABILITY, OR OTHER CHARACTERISTICS PROTECTED BY LAW.