Clinical Quality Assurance Nurse Consultant

2 weeks ago


Providence, Rhode Island, United States US Tech Solutions Full time

Position Overview:

The Quality Management Nurse Consultant plays a crucial role in ensuring the highest standards of clinical care. This position involves a thorough review and assessment of clinical documentation and information.

Key Responsibilities:

  • Conducting comprehensive evaluations of clinical records to ensure adherence to established clinical criteria and policies.
  • Independently managing clinical resolutions, collaborating with clinicians as necessary.
  • Identifying potential quality of care concerns in accordance with clinical policies and benefit determinations.
  • Utilizing various systems to gather and analyze relevant data.
  • Engaging with healthcare providers, vendors, and internal departments to obtain additional information as needed.
  • Ensuring compliance with clinical policies, regulatory standards, and accreditation requirements.
  • Facilitating case reviews by qualified practitioners with the appropriate clinical expertise.
  • Maintaining an in-depth understanding of contracts, delegation arrangements, clinical criteria, and company policies.
  • Applying regulatory and accreditation standards consistently to ensure all activities are compliant.
  • Summarizing complex clinical information into a coherent overview while working autonomously.

Qualifications:

  • Significant clinical experience is required.
  • Familiarity with Medcompass is essential.
  • Experience in prior authorization processes is necessary.
  • Preferred background in Managed Care or Medicare.

Essential Skills:

  • Proficiency in Medcompass or Assurecare systems.
  • Knowledge of Managed Care and Medicare/Medicaid frameworks.
  • Experience in Utilization Management, particularly inpatient reviews.
  • Extensive experience in utilization management, with familiarity in Milliman/MCG guidelines.
  • Experience in prior authorization processes is required.

Educational Requirements:

  • Registered Nurse (RN) with an active and unrestricted state license.

About US Tech Solutions:

US Tech Solutions is a leading global staffing firm dedicated to providing a diverse range of talent and comprehensive workforce solutions. We are committed to fostering an inclusive and diverse workplace.



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