Remote Insurance Utilization Review Jobs in Pittsburgh, PA

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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- 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 include:
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
This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee. Duties, responsibilities and activities may change or new ones may be assigned at any time with or without notice.
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.
This position qualifies for the following Company benefits: Medical/Dental/Vision, FSA and HSA, group life/AD&D, voluntary life/AD&D, 401k
For immediate consideration, please apply via the HQSI Careers Page at: www.hqsi.org > Careers > Current Employment Opportunities
EOE: Minorities/Females/Disabled/Veterans
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