Quality and utilization review nurse

Job Summary
We are seeking a highly skilled and detail-oriented Quality and Utilization Review Nurse to join our healthcare team. This role involves evaluating medical records, ensuring compliance with clinical standards, and supporting utilization management processes. The ideal candidate will possess strong clinical knowledge, proficiency with electronic health record (EHR) systems, and experience in various healthcare settings including inpatient and outpatient. This position offers an opportunity to contribute to quality improvement initiatives and ensure optimal patient care delivery through meticulous documentation review and case management.

Responsibilities

• Conduct thorough reviews of medical documentation, including clinical notes, coding, and discharge summaries to ensure accuracy and completeness.
• Evaluate medical records for compliance with HIPAA regulations, NCQA standards, and other regulatory requirements.
• Perform utilization management activities by assessing the appropriateness of services, admissions, and lengths of stay across various care settings such as acute care, home care, hospice, and skilled nursing facilities.
• Collaborate with healthcare providers to facilitate discharge planning, case management, and clinical documentation improvement initiatives.
• Utilize EMR/EHR systems to review patient data efficiently.
• Apply knowledge of physiology, anatomy, medical terminology, and coding systems to support accurate case assessments.
• Support Medicare and managed care programs by ensuring documentation aligns with payer requirements.
• Participate in ongoing quality assurance activities to maintain compliance with hospital accreditation standards criteria.
• Maintain detailed records of review findings and communicate recommendations clearly to multidisciplinary teams.

Skills

• Proficiency with EMR/EHR systems.
• Strong knowledge of medical coding and documentation review processes.
• Familiarity with managed care policies, Medicare requirements, NCQA standards, and healthcare regulations including HIPAA.
• Excellent critical thinking skills with the ability to analyze complex clinical data accurately.
• Effective communication skills for collaborating with healthcare providers and documenting findings clearly.
• Knowledge of physiology, anatomy, medical terminology, and medical records management.
• Prior experience in discharge planning, case management or clinical documentation improvement is preferred.
• Ability to work independently while managing multiple cases efficiently. This position is integral to maintaining high standards of patient care while ensuring compliance with healthcare regulations and payer policies. The successful candidate will bring a comprehensive understanding of clinical workflows combined with technical proficiency in health information management systems.

Pay: $32.00 - $40.00 per hour

Expected hours: 36.0 – 40.0 per week

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Disability insurance
• Employee assistance program
• Flexible schedule
• Flexible spending account
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Vision insurance

Work Location: In person

Salary : $32 - $40