Quality Assurance Nurse (Remote)

Nexus Enterprises LLC•Schertz, TX

9d•Remote

About The Position

Under the direct supervision of the Quality Assurance (QA) Director, the QA Nurse is responsible for conducting systematic audits of random Utilization Review (UR) cases to evaluate conformance with established guidelines; focus is on continuous quality improvement. Essential Job Functions: • Review and evaluate a random sample of completed UR cases daily against client specific requirements, contractual guidelines, Federal, State, and local regulations, and/or evidence-based practice using established parameters • Review completed UR cases, prior to physician review, to identify errors or other opportunities for process improvement (i.e., use of correct clinical criteria, impediments to meeting TAT, clear and concise denial language, and criteria, etc.) • Assist in the development of UR policies, procedures, training, and QA projects based on data collected from case reviews • Assist in the collection and analysis of data against defined metrics • Identify, track and trend discrepancies used to initiate and identify needed corrective action plans • Responsible for high-quality, cyclical, professional QA reports free of grammar or spelling errors submitted to QA leadership • Reports include at a minimum: total number of clarifications by UR nurse; categories of clarifications; percentages; comparison by month/quarter/year; and detailed performance improvement feedback • Assist the QA Director to develop recommendations and follow-up activity based on root cause analysis with a focus on improved quality and efficiency • Complete mandatory daily quota of audits with a high degree of accuracy: Reach and maintain a 15-20 average daily case load (combination of Peer Reviews and internal case/file reviews) within a specified timeframe with at least a 97% accuracy rate • Communicate with QA Management on urgent issues, objectives and areas of needed improvement that require immediate attention • Use logic and reasoning to interpret, analyze, and apply appropriate guidelines to medical-legal reviews and supporting clinical documentation • Use evidenced-based research to review and comprehend medical/surgical modalities and imaging techniques to evaluate the standards of care identified. • Apply pre-approved criteria and guidelines to validate medical necessity/appropriateness of treatment (e.g., ODG, MTUS, Milliman Care Guidelines, InterQual • Maintain appropriate discretion with regard to confidential or sensitive information. Refrain from discussing with unauthorized people • Maintain and expand professional competence in quality assurance and auditing • Perform a low to moderate amount of research on a case-by-case basis • Electronically file and retrieve corporate documents, records, and reports • Participates in an interdisciplinary health care team environment • Effectively communicate with internal and external customers (both orally and in writing) • Compose and prepare correspondence • Regular and consistent attendance required • Other duties as assigned

Requirements

Must be extremely detail-oriented, quality driven; able to follow a detailed checklist systematically and develop own system as needed for organizing/tracking work processes
Previous experience in UR or auditing in a managed care or healthcare setting
Expert level written and verbal communication skills
Proficiency in English with an aptitude for spelling and grammar
Ability to work in high pressure, deadline driven environment with strong time management skills
Must be capable of performing routine job functions with minimal supervision
Strong ability to review clinical charts and documents for accuracy and completion
Demonstrated ability to problem solve complex, multifaceted, situations
Professional demeanor; ability to build rapport amongst staff and to provide constructive feedback
Maintain a positive attitude and outstanding customer service while working closely internally with Nexus staff, panel physicians, and clients
Must be able to give clear and accurate information with polite, persistent follow-up
Ability to use Microsoft products; Word, Excel, PowerPoint, Outlook
General Typing Skills at 45wpm
Active RN licensure required
2-3 years of workers compensation management, clinical review & QA clinical review is required
Active & Unrestricted RN license required

Nice To Haves

BSN is preferred

Responsibilities

Review and evaluate a random sample of completed UR cases daily against client specific requirements, contractual guidelines, Federal, State, and local regulations, and/or evidence-based practice using established parameters
Review completed UR cases, prior to physician review, to identify errors or other opportunities for process improvement (i.e., use of correct clinical criteria, impediments to meeting TAT, clear and concise denial language, and criteria, etc.)
Assist in the development of UR policies, procedures, training, and QA projects based on data collected from case reviews
Assist in the collection and analysis of data against defined metrics
Identify, track and trend discrepancies used to initiate and identify needed corrective action plans
Responsible for high-quality, cyclical, professional QA reports free of grammar or spelling errors submitted to QA leadership
Assist the QA Director to develop recommendations and follow-up activity based on root cause analysis with a focus on improved quality and efficiency
Complete mandatory daily quota of audits with a high degree of accuracy
Communicate with QA Management on urgent issues, objectives and areas of needed improvement that require immediate attention
Use logic and reasoning to interpret, analyze, and apply appropriate guidelines to medical-legal reviews and supporting clinical documentation
Use evidenced-based research to review and comprehend medical/surgical modalities and imaging techniques to evaluate the standards of care identified.
Apply pre-approved criteria and guidelines to validate medical necessity/appropriateness of treatment
Maintain appropriate discretion with regard to confidential or sensitive information.
Maintain and expand professional competence in quality assurance and auditing
Perform a low to moderate amount of research on a case-by-case basis
Electronically file and retrieve corporate documents, records, and reports
Participates in an interdisciplinary health care team environment
Effectively communicate with internal and external customers (both orally and in writing)
Compose and prepare correspondence
Regular and consistent attendance required
Other duties as assigned