Nurse Reviewer II Position

3 weeks ago


Saint Paul, Minnesota, United States Health Services Advisory Group Full time

Health Services Advisory Group (HSAG) is seeking a skilled Nurse Reviewer II to join our team in Honolulu, Hawaii. As a key member of our team, you will be responsible for coordinating and conducting various review activities as defined by our contract with the State of Hawaii, Department of Human Services MedQUEST Division (DHS/MQD).

Clinical review activities include long-term care level of care (LTC LOC) evaluations and determinations, Preadmission Screening and Resident Review (PASRR) compliance audits, and peer review of quality of care (QOC) concerns.

You will use professional judgment to apply the appropriate, established screening criteria and ensure timely and accurate completion of all assigned review activities, including data entry into the Hawaii level of care (HILOC) and ePASRR electronic databases.

As a Nurse Reviewer II, you will work closely with our medical director on level of care evaluations that do not meet established guidelines and assist with QOC reviews and report writing.

You will also be responsible for assisting the production of the monthly, quarterly, and annual reporting of review activities.

Key Responsibilities:

  • Independently conduct LTC LOC determinations and PASRR reviews within established DHS/MQD timelines; maintain 90 percent accuracy overall.
  • Use appropriate, established screening criteria (State of Hawaii criteria for LOC decisions) to each LTC LOC determination; maintain 90 percent accuracy overall.
  • Use critical thinking skills and professional judgment to identify potential utilization and QOC concerns; clearly communicate case referrals to DHS/MQD RN consultant.
  • Communicate with Medicaid beneficiaries and applicants, physicians, administrators, and other professional staff on case review processes, case determinations, and report findings.
  • Conduct training and educational seminars with educate providers and beneficiaries on Medicaid requirements as they relate to review/oversight activities; provide technical assistance to DHS/MQD, QUEST integrated health plans, and providers/facilities.

Requirements:

  • Bachelor's degree in nursing is required.
  • Must hold an active, unencumbered RN license in the State of Hawaii.
  • Must have at least three years of clinical nursing experience. Acute care and/or long-term care experience preferred.
  • Knowledge of the Hawaii health care delivery system and Medicaid programs is preferred.

Work Environment:

This is a work-from-home position, and the employee must live in the State of Hawaii and have a designated workspace that allows for uninterrupted virtual meetings and phone calls.

Occasionally, the employee may need to attend meetings at our office located in Kapolei, Hawaii, or trainings at health care facilities on Oahu and the neighbor islands.


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