Quality Review Nurse

Versant Health • Troy, NY

2d

About The Position

The Quality Review Nurse works within the Utilization Management team to bring additional clinical expertise to the prior authorization and denial review processes. The Quality Review Nurse applies specific criteria and payer guidelines to ensure that all healthcare services provided are optimized for quality and timeliness of the care. This role serves as the clinical support person for the Utilization Management Team and as a subject matter expert (SME) for member friendly language and denial letter review.

Requirements

• Graduate of an accredited Practical Nursing program required.
• 3+ years of related experience in utilization management required
• 3+ years of clinical experience in acute care required
• Proficiency in Microsoft Office suite required
• Active, unrestricted LNP or LVN license in state of residence, or compact state licensure required.

Nice To Haves

• Knowledge and experience in the insurance, health, or vision care industry perferred

Responsibilities

• Serve as a clinical resource to the Utilization Management Team
• Serve as a SME for member friendly language notification letters
• Provide quality clinical review and edits of all denial letters to ensure NCQA requirements are met
• Maintain a quality tracking log of all letters reviewed
• Quality Clinical Review of authorization requests
• Apply specific medical criteria and payer guidelines when reviewing clinical documentation for medical necessity
• Ensure services provided to eligible members are within the benefit plan and that appropriate contracted providers are being utilized
• Identify and refer cases for second level review when necessary
• Follow and apply all regulatory requirements for assigned markets
• Monitor reporting to track missing diagnosis codes and update prior authorization to reflect properly assigned diagnosis codes on a weekly basis
• Work closely with utilization management leadership to ensure the continual compliance of all QA/QI initiatives
• Contribute to a positive work culture by modeling excellence in both work ethic and team interactions
• Perform additional duties as assigned

Benefits

• We offer a comprehensive and competitive total rewards package designed to support your health, financial well‑being, and work‑life balance. Benefits include medical, dental, and paid vision coverage; paid time off and company holidays; retirement savings with employer contribution; employee wellness resources; and professional development opportunities. Additional benefits may include flexible work arrangements, employee assistance programs, and other programs that support you both at work and beyond.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed