Clinical Quality Assurance Nurse Auditor (29174)

Description

The Clinical Quality Assurance Nurse Auditor is responsible for evaluating clinical information received from various healthcare providers and writes reports based on clinical information received. This position ensures reports are completed with highest quality and integrity and that all work is in full compliance with client contractual agreements, regulatory agency standards and federal and state mandates. This position is required to handle quality assurance questions and provide overall support to the Quality Assurance Department.

ESSENTIAL JOB FUNCTIONS

• Evaluate clinical information received, write and/or review various reports including, but not limited to, Medical Record Reviews, Medical Record Chronologies, Provider Bill Reviews, Coding Reviews, Hospital Bill Reviews, List of Missing Records, Medical Bill Apportionments, Mock Billing Invoice and Medical Summary Statements.
• Perform quality assurance review of peer review reports, correspondences, addendums or supplemental reviews.
• Ensure clear, concise, evidence-based rationales have been provided in support of all recommendations and/or determinations.
• Ensure that all client instructions and specifications have been followed and that all questions have been addressed.
• Ensure each review is supported by clinical citations and references when applicable and verify that all references cited are current and obtained from reputable medical journals and/or publications.
• Ensure the content, format, and professional appearance of the reports are of the highest quality and in compliance with company standards.
• Ensure the appropriate board specialty has reviewed the case in compliance with client specifications and/or state mandates and is documented accurately on the case report.
• Verify that the reviewer has attested to only the facts and that no evidence of reviewer conflict of interest exists.
• Ensure the provider credentials and signature are adhered to the final report.
• Identify any inconsistencies within the report and contacts the Reviewer to obtain clarification, modification or correction as needed.
• Contact the appropriate person to recover any missing documentation or verify charges.
• Assist in resolution of customer complaints and quality assurance issues as needed.
• Ensure all federal ERISA or state mandates are adhered to at all times.
• Provide insight and direction to management on consultant quality, availability and compliance with all company policies and procedures and client specifications.
• Promote effective and efficient utilization of company resources.
• Participate in various continuing education requirements and or training activities.
• Perform other duties as assigned.
  
  

Qualifications

Education and/or Experience

Bachelor/Associate degree in nursing or related field; or minimum five years related experience; or equivalent combination of education and experience. Experience with medical terminology, medications, medical specialties and treatment protocols required. Experience in the insurance industry preferred.

Certificates, Licenses, Registrations

RN/LPN license

ESSENTIAL JOB FUNCTIONS

• Evaluate clinical information received, write and/or review various reports including, but not limited to, Medical Record Reviews, Medical Record Chronologies, Provider Bill Reviews, Coding Reviews, Hospital Bill Reviews, List of Missing Records, Medical Bill Apportionments, Mock Billing Invoice and Medical Summary Statements.
• Perform quality assurance review of peer review reports, correspondences, addendums or supplemental reviews.
• Ensure clear, concise, evidence-based rationales have been provided in support of all recommendations and/or determinations.
• Ensure that all client instructions and specifications have been followed and that all questions have been addressed.
• Ensure each review is supported by clinical citations and references when applicable and verify that all references cited are current and obtained from reputable medical journals and/or publications.
• Ensure the content, format, and professional appearance of the reports are of the highest quality and in compliance with company standards.
• Ensure the appropriate board specialty has reviewed the case in compliance with client specifications and/or state mandates and is documented accurately on the case report.
• Verify that the reviewer has attested to only the facts and that no evidence of reviewer conflict of interest exists.
• Ensure the provider credentials and signature are adhered to the final report.
• Identify any inconsistencies within the report and contacts the Reviewer to obtain clarification, modification or correction as needed.
• Contact the appropriate person to recover any missing documentation or verify charges.
• Assist in resolution of customer complaints and quality assurance issues as needed.
• Ensure all federal ERISA or state mandates are adhered to at all times.
• Provide insight and direction to management on consultant quality, availability and compliance with all company policies and procedures and client specifications.
• Promote effective and efficient utilization of company resources.
• Participate in various continuing education requirements and or training activities.
• Perform other duties as assigned.