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Clinical Quality Assurance Nurse Consultant
2 months ago
Position Overview:
The Quality Management Nurse Consultant plays a pivotal role in ensuring the highest standards of clinical care. This position involves a thorough examination and assessment of clinical documentation and information.
Key Responsibilities:
- Conducting comprehensive reviews of clinical records to interpret data and apply relevant clinical criteria and policies.
- Independently managing clinical resolutions while collaborating with clinicians as necessary.
- Identifying potential quality of care concerns based on established clinical policies and benefit determinations.
- Utilizing various system applications to gather and analyze data effectively.
- Engaging with providers, vendors, and internal healthcare departments to obtain supplementary information.
- Ensuring compliance with clinical policies, regulatory standards, and accreditation requirements.
- Overseeing that cases are reviewed by qualified practitioners with appropriate clinical expertise.
- Maintaining a thorough understanding of delegation agreements, contracts, clinical criteria, and company policies.
- Applying regulatory and accreditation standards consistently to ensure adherence to guidelines.
- Summarizing intricate information into a coherent clinical overview while working autonomously.
Qualifications:
- Significant years of clinical experience are essential.
- Experience with Medcompass is required.
- Prior authorization utilization experience is necessary.
- Managed Care or Medicare experience is preferred.
Required Skills:
- Proficiency in Medcompass or Assurecare is mandatory.
- Knowledge of Managed Care and Medicare/Medicaid is essential.
- Experience in Utilization Management, particularly inpatient utilization management review, is required.
- Extensive experience in utilization management, with familiarity in Milliman/MCG preferred.
- Prior authorization experience is necessary.
Educational Requirements:
- Current unrestricted RN licensure in the state is required.
About US Tech Solutions:
US Tech Solutions is a global staffing firm that provides a diverse range of talent on-demand and comprehensive workforce solutions. As an Equal Opportunity Employer, we prioritize diversity and inclusivity within our workplace.
