Review Nurse – Quality
Job Locations: Remote
Job ID: 2019-7695
Category: Clinical/Utilization Management
Imagine being able to shape the healthcare industry where people can heal and age at home
The Quality Review Nurse (QRN) is responsible for supporting quality improvement initiatives aimed at achieving and maintaining a high standard of care and service excellence to CareCentrix’s patients, Health Plan customers, and accredited Providers.
The QRN accomplishes this through involvement in quality projects and in participating in the end-to-end auditing process including data sampling, file extraction, analysis, trending and reporting of clinical and service indicators and recommendations as needed.
CareCentrix is a growing organization and we are seeking dedicated individuals to be a part of this exciting and rewarding business. We offer competitive pay plus bonus and a full benefit package including PTO, health, dental, vision, 401K, tuition reimbursement, and more!
- This position of Quality Review Nurse assists in the clinical quality of care review process, the medical record audit process for the delegation oversight, quantitative and qualitative analysis of data & transformation in information that can be reported
- Performs delegation oversight activities including auditing medical record against Medical Care guidelines, scope of professional practice standards and policies and procedures, etc., to determine compliance with established standards
- Assists in developing oversight tools and processes for clinical quality
- Extracts data from systems and records and conducts quantitative and qualitative analysis of data and transformation into information that can be reported
- Works with account/network management and/or Provider Services staff to ensure provider understanding and compliance with required elements of delegated functions
- Works with clinical review staff to ensure compliance with delegated functions
- Participates in and contributes to performance improvement activities through clinical review of complex cases and coaching activities to expand and develop clinical skill for licensed associates.
- Associate Degree required, with Bachelor’s or Master’s degree preferred.
- Current Registered Nurse license in the state(s) of practice without restrictions and a strong clinical background as an RN (minimum of 5 years)
- Certified Professional Health Care Quality (CPHQ) preferred.
- 3-5 years of Quality Management and/or UM in a managed care environment
- Prior experience with medical record review, complaint review, investigation and tracking.
- Past experience with data collection and analysis of indicators for monitoring and evaluation of quality, appropriateness and timeliness of care and service, and customer satisfaction