Clinical Quality Assurance Nurse
1 week ago
Position Summary:
We are seeking a dedicated and detail-oriented Clinical Quality Assurance Nurse to join our team at TulaRay. This role is essential in ensuring compliance with healthcare regulations and maintaining high standards of patient care.
Minimum Qualifications:
- Current licensure as a Registered Nurse from the Pennsylvania State Board of Nursing or a valid temporary practice permit.
- Proficient in written communication and basic computer skills, including Microsoft Office Suite.
- A minimum of three years of professional experience in medical assistance, healthcare services, or human services.
- Recent experience (within the last five years) in long-term care, acute care, behavioral health, drug and alcohol settings, managed care, or quality management/utilization review is preferred.
- Equivalent combinations of experience and training in relevant fields will be considered.
Key Responsibilities:
- Conduct thorough analyses of paid claims and itemized bills to identify discrepancies and patterns related to high-cost providers.
- Review and evaluate cases to ensure compliance with state and federal regulations, focusing on medical necessity and quality of care.
- Investigate potential issues such as upcoding, duplicate billing, and unbundling of services, utilizing coding manuals and provider handbooks.
- Prepare comprehensive case findings and collaborate with physician consultants to communicate results to providers.
- Maintain accurate records and updates in the Bureau's Case Tracking system for all active cases.
- Coordinate and participate in meetings and teleconferences with relevant stakeholders to discuss case findings and review processes.
- Engage in evidentiary meetings to discuss case strategies and prepare for potential litigation proceedings.
- Respond to inquiries and complaints from various sources, ensuring thorough and timely communication.
Essential Skills:
1. Proficient in Microsoft Office, especially Excel.
2. Strong verbal and written communication skills.
3. Ability to prepare detailed reports and correspondence.
4. Knowledge of healthcare regulations and compliance standards.
5. Strong analytical and problem-solving abilities.
6. Ability to maintain confidentiality and exercise discretion.
7. Willingness to travel for on-site visits and meetings as required.
About TulaRay:
TulaRay is committed to delivering exceptional staffing solutions tailored to meet the unique needs of our clients. We prioritize quality and personalized service, ensuring that our healthcare personnel meet the highest standards. As an affirmative action employer, we are dedicated to fostering an inclusive workplace that values diversity and equal opportunity.
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