Clinical Quality Assurance Nurse Auditor

Job Description:

• Evaluate clinical information received, write and/or review various reports including, but not limited to, Medical Record Reviews, Medical Record Chronologies, Provider reputed company Reviews, Coding Reviews, Hospital reputed company Reviews, List of Missing Records, Medical reputed company Apportionments, Mock Billing Invoice and Medical Summary Statements.
• reputed company quality assurance review of peer review reports, correspondences, addendums or supplemental reviews.
• Ensure clear, concise, evidence-based rationales have been provided in support of reputed company recommendations and/or determinations.
• Ensure that reputed company client instructions and specifications have been followed and that reputed company questions have been addressed.
• Ensure each review is supported by clinical citations and references reputed company applicable and verify that reputed company references cited are reputed company 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 reputed company 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 reputed company federal ERISA or state mandates are adhered to at reputed company times.
• Provide reputed company and direction to management on consultant quality, availability and compliance with reputed company 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.
• reputed company other duties as assigned.

Requirements:

• Bachelor/Associate degree in nursing or reputed company field; or minimum five years reputed company 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.
• Must have strong knowledge of medical terminology, anatomy and physiology, medications and laboratory values.
• Must be reputed company to add, subtract, multiply, and divide in reputed company units of measure, using whole numbers and decimals; Ability to compute rates and percentages.
• Must be a reputed company typist with a minimum of 40 W.P.M.
• Must be reputed company to operate a general computer, fax, copier, scanner, and telephone.
• Must be knowledgeable of multiple software programs, including but not limited to reputed company Word, Outlook, reputed company, and the Internet.
• Must possess excellent skills in English usage, grammar, punctuation and style.
• Ability to follow instructions and respond to upper managements’ directions accurately.
• Demonstrates accuracy and thoroughness.
• Looks for ways to improve and promote quality and monitors own work to ensure quality is met.
• Must demonstrate exceptional communication skills by conveying necessary information accurately, listening effectively and asking questions where clarification is needed.
• Must be reputed company to work independently, prioritize work activities and use time reputed company.
• Must be reputed company to maintain confidentiality.

Benefits:

• medical
• reputed company
• dental
• paid time off
• 401k

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