Nurse Reviewer - Tampa, FL

Healthcare Quality Strategies, Inc. (HQSI); Florida; On-site; USD 45,460 - 64,747; Part time

Benefits offered by this job

Medical/Dental/Vision

FSA and HSA

Group life/AD&D

Voluntary life/AD&D

401k

Job summary

Healthcare Quality Strategies, Inc. (HQSI) is seeking a Nurse Reviewer for a remote position supporting Medical Review Services. The role requires conducting comprehensive medical necessity reviews and ensuring compliance with established guidelines.

The ideal candidate will have a BSN with active RN licensure and 3-5 years of experience in medical record review. Proficiency in medical terminology and excellent communication skills are essential. Benefits include medical/dental/vision insurance and 401k.

Qualifications

• At least three to five years performing medical record review and/or abstraction.
• Knowledge and experience of Medicare and Medicaid policy.
• Current experience in the application of clinical screening criteria (InterQual and MCG).

Responsibilities

• Conduct comprehensive medical record reviews to assess medical necessity.
• Manage end-to-end case screening processes.
• Evaluate medical claims against industry standards.

Skills

Medical terminology, ICD-10, CPT and HCPCS

Clinical criteria (InterQual and MCG)

Utilization/Medical record review and chart abstraction

Current standards of medical practice

Professional interpersonal skills

Strong attention to detail

Effective written and verbal communication

Education

BSN with active RN licensure in good standing

Tools

Microsoft Office (Word, Excel, and Outlook)

Adobe PDF files and features

Job description

Nurse Reviewer

Position Details

PT (20-30 hours week) – Remote Work Environment

Non-Exempt: $40.00 hour

Supports Medical Review Services. The Nurse Reviewer plays a critical role in supporting the Medical Review Services department by performing comprehensive medical necessity reviews and policy reviews for Medicaid claims. This involves meticulous examination of claims and medical records to ensure compliance with established guidelines and regulations. The RN will work closely with the Team Lead, Physician Peer Reviewer and contract team. Reviews must be completed timely.

Essential Duties and Responsibilities

• Conduct comprehensive medical record reviews to assess medical necessity and compliance with established standards of care and applicable policies
• Manage end-to-end case screening processes, ensuring all activities are completed within established deadlines
• Document evidence-based criteria applicable to specific contract requirements
• Record and report screening results, including relevant referral questions, into a centralized database
• Evaluate medical claims against industry standards, utilizing research of relevant ICD-10, CPT, and HCPCS codes to determine medical necessity
• Maintain expert knowledge of evolving multi-state Medicaid policies and vendor expectations
• Participate in ongoing training and consistently meet or exceed productivity and quality assurance standards

Knowledge, Experience, Skills and Education

• Medical terminology, ICD-10, CPT and HCPCS
• Clinical criteria (InterQual and MCG)
• Utilization/Medical record review and chart abstraction
• Current standards of medical practice
• Comply with HIPAA/HITECH laws and regulations

Experience In

• At least three to five years performing medical record review and/or abstraction (Utilization Review experience preferred)
• Experience performing medical record review, audit for federal or state contracts
• Knowledge and experience of Medicare and Medicaid policy
• Proficiency with Microsoft Office (Word, Excel, and Outlook)
• Proficiency with Adobe PDF files and features
• Generating accurate, timely, and understandable correspondence
• Current experience (within the last 3 years) in the application of clinical screening criteria (InterQual and MCG)

Skills Requirements

• Professional interpersonal skills; ability to interact with providers, physicians and peers
• Solid analytical, assessment and documentation skills
• Effective written and verbal communication, both internally and externally
• Strong attention to detail
• Strong attention to deadlines
• Organizational skills including effective time management, priority setting and process improvement
• Ability to work independently and as a member of a team
• Adapt to changing work situations and readily adjusts schedules, tasks and priorities when necessary to meet business fluctuations

Educational Background

• BSN with active RN licensure in good standing

Physical Demands

Remote Work, Prolonged Sitting, Screen Exposure

Benefits

Medical/Dental/Vision, FSA and HSA, group life/AD&D, voluntary life/AD&D, 401k

Equal Opportunity Employer

Healthcare Quality Strategies, Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. Healthcare Quality Strategies, Inc. is Equal Opportunity, affirmative action employer and an alcohol/drug free workplace. Healthcare Quality Strategies, Inc. is an E-Verify employer.