Job Description

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 reviewsto 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 criteriaapplicable 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 policiesand vendor expectations
• Participate in ongoing trainingand 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: > Careers > Current Employment Opportunities

EOE: Minorities/Females/Disabled/Veterans

Healthcare Quality Strategies, Inc. is Equal Opportunity, Aff

Healthcare Quality Strategies, Inc. is an E-Verify Employer

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