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Clinical Quality Assurance Nurse Consultant
2 months ago
The Quality Management Nurse Consultant plays a pivotal role in assessing and analyzing clinical documentation and information.
Key Responsibilities:- Conducts thorough reviews of clinical records to ensure compliance with established clinical criteria and regulatory standards.
- Interprets data from various clinical systems to support accurate decision-making regarding member and provider issues.
- Independently facilitates clinical resolutions, collaborating with both internal and external healthcare professionals as necessary.
- Evaluates clinical documentation to identify potential quality of care concerns in accordance with clinical policies.
- Integrates all relevant system information and supplementary records to formulate informed recommendations.
- Engages in data collection across multiple system platforms, ensuring comprehensive analysis.
- May require direct communication with healthcare providers, vendors, or internal departments to gather additional insights.
- Assesses documentation for adherence to clinical policies, regulatory mandates, and accreditation standards.
- Ensures that cases are reviewed by qualified practitioners with the necessary clinical expertise.
- Possesses in-depth knowledge of complex contractual arrangements, clinical criteria, and regulatory requirements essential for effective documentation review.
- Consistently applies regulatory and accreditation standards to guarantee compliance in all review activities.
- Effectively synthesizes complex information into a clear clinical narrative while working autonomously.
- A minimum of 3 years of clinical experience is required.
- Experience with Medcompass is essential.
- Prior authorization utilization experience is mandatory.
- Experience in Managed Care or Medicare is preferred.
- Proficiency in Medcompass or AssureCare is a must.
- Experience in Managed Care along with knowledge of Medicare/Medicaid is required.
- Experience in Utilization Management, particularly inpatient reviews, is essential.
- A minimum of 1 year of experience in Utilization Management is required, with a preference for familiarity with Milliman/MCG guidelines.
- At least 6 months of experience in Prior Authorization is necessary.
- Registered Nurse (RN) with current unrestricted state licensure.
US Tech Solutions is a global staffing firm that provides a diverse range of talent on-demand and comprehensive workforce solutions. For more information about US Tech Solutions, please visit our website.
US Tech Solutions is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.
