Clinical Quality Assurance Nurse

2 weeks ago

Albany, New York, United States Versant Health Full time

Position Overview

The Clinical Quality Assurance Nurse plays a pivotal role within the Utilization Management division, providing essential clinical insight to enhance the prior authorization and denial review processes. This position requires the application of specific criteria and payer guidelines to ensure that healthcare services are delivered with optimal quality and efficiency across all lines of business, including Medicare, Medicaid, and Commercial sectors.

Key Responsibilities

The Quality Assurance Nurse will:

  • Act as a clinical resource for the Utilization Management team.
  • Serve as a subject-matter expert (SME) for member-friendly communication and denial letter assessments.
  • Conduct thorough clinical reviews of denial letters, ensuring compliance with NCQA and regulatory standards.
  • Utilize medical criteria and payer guidelines to evaluate clinical documentation for medical necessity.
  • Verify that services provided to eligible members align with benefit plans and that appropriate contracted providers are utilized.
  • Maintain a quality tracking log for all reviewed letters.
  • Perform quality clinical reviews of authorization requests.
  • Identify and escalate cases for second-level review when necessary.
  • Adhere to all regulatory requirements relevant to assigned markets.
  • Monitor reporting to identify missing diagnosis codes and update prior authorizations accordingly on a weekly basis.
  • Collaborate closely with utilization management leadership to ensure ongoing compliance with all QA/QI initiatives.
  • Contribute positively to the workplace culture by exemplifying excellence in work ethic and team collaboration.
  • Undertake additional duties as assigned.

Qualifications
  • Graduation from an accredited nursing program.
  • Possession of a current unrestricted LPN or RN license in the state of residence or compact state licensure.
  • A minimum of 3 years of relevant experience in utilization management.
  • At least 3 years of clinical experience in acute care settings.
  • Preferred knowledge and experience in the insurance, health, or vision care sectors.
  • Proficiency in Microsoft Office Suite.

Compliance and Security

All associates are required to comply with the Health Insurance Portability Accountability Act of 1996 (HIPAA) regarding the handling of protected health information (PHI). Associates may have access to confidential customer information that must be safeguarded at all times, adhering to the company's established data security guidelines.

Versant Health is committed to fostering a diverse and inclusive workforce and is an Equal Employment Opportunity and Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, age, disability, national origin, marital status, genetic information, or veteran status.

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