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Registered Nurse - RN - Quality Assurance

ProPeer Resources
Chicago, IL
  • Posted: over a month ago
  • Full-Time
  • Benefits: medical, vision, 401k, dental, life insurance,
Job Description

Job Summary:

The QA Nurse position supports the Independent Review Organization (IRO) in quality assurance efforts of commercial health non-appeal, internal appeal, state external appeal and Federal PPACA appeal cases. All QA Nurses are responsible for conducting quality assurance checks to include analyzing of medical records, prior denials, ensuring proper clinical specialty is utilized for reviews, and appropriate evidence-based literature is used in support of rationale. Additionally, the QA Nurses ensure that details of the patient’s condition, physician orders, course of treatment and well supported rationale are present within the clinical reviewer’s final review.

 

Major Duties and Responsibilities:

  • Comprehension of medical/surgical modalities and imaging techniques
  • Ability to analyze clinical documentation, prior denials and supporting documentation to ensure the quality of the clinical reviewer’s final review
  • Audit and analyze patient records to ensure quality patient care and appropriateness of services
  • Utilize pre-approved criteria/guidelines and plan language to validate medical necessity/appropriateness of treatment (e.g. Policy Plan Language, Milliman Care Guidelines, Interqual)
  • Ability to understand and analyze plan language documentation
  • Understanding of proper citation of evidence-based literature and requirements of clients
  • Keeps current with regulation changes
  • Perform a low to moderate amount of research on a case by case basis
  • Conducts audit to ensure a high-quality, professional report free of grammar and spelling errors is delivered to the client
  • Communicate with physician reviewers to address/correct errors or omissions and to investigate questionable claims
  • Responsible for amending reports when necessary with any additional clinical information provided
  • Participates in an interdisciplinary health care team to achieve positive outcomes
  • Ability to complete average daily case load of 15-20 cases once released from training
  • Requires regular and consistent attendance
  • Other duties as assigned

Knowledge and Abilities Requirements:

  • Knowledge of Basic Anatomy
  • Comprehension of medical/surgical modalities and imaging techniques
  • Ability to analyze clinical documentation in relation to utilization reviews
  • Ability to Interpret and apply appropriate guidelines to utilization reviews
  • Ability to use logic and reasoning to determine and utilize appropriate evidence-based guidelines
  • Ability to read, analyze, and interpret documents, reports, technical procedures, governmental regulation, and correspondence.
  • Ability to write routine reports and correspondence; and ability to present information in one-on-one, small group, and large group situations to management and staff.
  • Ability to apply proper grammar, spelling, punctuation, and format to typed material.
  • General Typing Skills at 45wpm
  • Ability to use Microsoft products, Word, Excel, PowerPoint, Outlook
  • Perform various computer functions to include saving, copying, pasting, scrolling, etc.
  • High level of oral and written communication skills with a demonstrated ability to deliver excellent customer service
  • Interact professionally and effectively with physician reviewers, staff, and clients from all departments within and outside the Company.
  • Demonstrated ability to work cross-functionally to solve complex problems and improve quality and service
  • Must have a track record of producing work that is highly accurate, demonstrating attention to detail
  • Build professional relationships that support the brand and its image
  • Ability to multi-task and quickly adapt in a fast-paced environment
  • Maintain a positive attitude and outstanding customer service while working closely internally with Nexus team-members, panel physicians and clients.
  • Strong organizational skills
  • Attention to detail
  • Proficiency in English with an aptitude for spelling and grammar
  • Exemplary planning and time management skills
  • Ability to multi-task, prioritize, and work in high pressure, deadline driven environment
  • Demonstrated ability to problem solve complex, multifaceted, situations
  • Ability to engage easily in abstract thought
  • Strong organizational and task prioritization skills

 

Education/Credentials:

  • RN with 1- 3 years of experience in Managed Care setting
  • Proficient computer skills; able to navigate through multiple software systems; knowledge of Microsoft Word, Excel, and Outlook

 

This job requires access to confidential and sensitive information, requiring ongoing discretion and secure information management.

Disclaimer

The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of our personnel. All ProPeer employees may be required to perform duties outside of their normal responsibilities from time to time, as needed.

Company Description
ProPeer Resources is your premier provider of independent specialty medical peer reviews. Since 1992, ProPeer Resources has been providing comprehensive and accurate independent medical peer reviews to claims departments across the nation - for health, disability, worker’s compensation, auto/personal injury, and life claims.

ProPeer Resources

Address

Chicago, IL
USA

Industry

Healthcare

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