Quality Assurance Review Nurse

Provider Resources, LLC; Erie (Erie County); On-site; USD 70,000 - 90,000; Full time

Job summary

A leading healthcare company is seeking a Quality Assurance Review Nurse to support medical review operations. The role involves comprehensive medical record reviews, ensuring compliance with regulations, and collaborating with clients and team members to enhance quality of care. The ideal candidate will possess a BSN, relevant experience, and strong communication skills.

Qualifications

• Minimum 3 years' supervisory experience in health insurance.
• Active RN license required.
• Certification in quality or utilization management preferred.

Responsibilities

• Perform medical record reviews for quality assurance.
• Coordinate with project team to meet contract obligations.
• Document review findings accurately.

Skills

Communication

Quality Assurance

Clinical Judgment

Education

Bachelor's Degree in Nursing

MSN

Tools

Microsoft Office Suite

InterQual

Milliman guidelines

Job description

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Position Description:

Quality Assurance Review Nurse

Reporting to the Director, the QA Review Nurse will provide professional assessment, planning, coordination, implementation, and reporting of complex clinical data to support the medical review operations of Provider Resources, Inc. (PRI). The nurse will perform comprehensive medical record reviews to make determinations on utilization, quality of care, and standards of care based on evidence-based standards, coverage policies, and guidelines.

Responsibilities

1. Understand and represent PRI's mission, vision, and values to all internal and external customers.
2. Interact professionally with government and private sector clients, partners, and PRI staff, representing PRI management.
3. Engage clients with appropriate communication to manage expectations and build collaboration.
4. Develop and maintain detailed project schedules, including administrative tasks.
5. Proactively manage activities to ensure timely delivery and exceed contractual obligations.
6. Coordinate with project team members to fulfill contract obligations with high quality, meeting ISO requirements.
7. Participate in ISO compliance activities, including timely submission of Corrective Action Plans and communicating outcomes to foster a culture of Continuous Quality Improvement.
8. Screen cases upon intake for referral to peer reviewers.
9. Perform medical record reviews in accordance with all applicable regulations.
10. Conduct QA for non-physician reviews and support project management.
11. Maintain compliance with regulation changes impacting review practices.
12. Analyze patient records and collaborate with PRI staff and partners.
13. Document review findings accurately and communicate results to supervisors.
14. Utilize electronic health information imaging and online resources for research.
15. Make clinical judgments based on evidence-based standards, review criteria, and nursing guidelines.
16. Perform other duties as assigned.

Requirements

1. Bachelor's Degree in Nursing (BSN), MSN preferred.
2. Minimum of three (3) years' supervisory/managerial experience in health insurance.
3. Extensive experience in medical review, utilization/quality assurance, and nursing standards.
4. Active Registered Nurse (RN) license in the state of residence.
5. Broad knowledge of healthcare delivery, case management, and regulatory agencies.
6. Knowledge of medical necessity standards, levels of care, inpatient/outpatient status.
7. Two or more years' experience in medical/utilization review and quality management.
8. Excellent communication and writing skills.
9. Knowledge of quality measures and national strategies.
10. Knowledge of ICD, CPT, HCPCS coding (desirable).
11. Proficiency in Microsoft Office Suite.
12. Certification in quality or utilization management (preferred).
13. Experience with InterQual and/or Milliman guidelines (preferred).
14. No pending adverse actions against licensing boards.
15. No conflicts of interest as per SSA regulations.
16. Ability to obtain and maintain U.S. Government Security Clearance.