Remote Clinical Quality Reviewer

US Family Health Plan- A TRICARE Prime option; New York (NY); Hybrid; USD 80,000 - 115,000; Full time

Benefits offered by this job

Medical coverage

Vision coverage

Dental benefits

401(k) employer match

Paid holidays

Job summary

US Family Health Plan- A TRICARE Prime option in New York seeks an experienced Clinical Quality Reviewer. The role conducts post-service in-depth clinical reviews across care settings, using clinical expertise to detect deviations from standard of care and gaps in care.

You will document investigations and final determinations while coordinating with providers and internal departments. The ideal candidate holds an RN or LPN license with 1–3 years of healthcare quality management experience and

Qualifications

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

Responsibilities

• Conduct post-service in-depth clinical reviews to identify deviation from standard of care or gaps in care.
• Document investigations and findings in internal databases and spreadsheets.
• Contact providers to obtain information and medical records for comprehensive reviews.
• Abstract data from charts and audits and summarize findings.
• Write succinct investigative summaries and quality review determinations.
• Develop relationships with stakeholders and vendor staff.
• Maintain confidentiality of medical records and documents.
• Meet strict deadlines and report outcomes.

Skills

Medical records analysis

Quality improvement

Data analysis

Nursing knowledge

Project management

MS Office

Education

RN license

LPN/LVN license

BA/BS preferred

Tools

Excel

Access

Visio

Outlook

PowerPoint

Job description

US Family Health Plan- A TRICARE Prime option in New York seeks an experienced Clinical Quality Reviewer. The role conducts post-service in-depth clinical reviews across care settings, using clinical expertise to detect deviations from standard of care and gaps in care.

You will document investigations and final determinations while coordinating with providers and internal departments. The ideal candidate holds an RN or LPN license with 1–3 years of healthcare quality management experience and