Clinical Quality Reviewer (RN) - Remote
Company: RCM Health Care
Location: New York
Posted on: January 27, 2023
This Health Plan based in Midtown Manhattan has been providing
care to the military community for over 30 years. Health care is
offered to active-duty family members, retirees and their family
members. - They offer world-class health care for their patients,
including wellness and disease prevention programs, disease
management, and continuity of care. The Health Plan were among the
first to implement the patient-centered medical home concept, and
they have been pioneers in tele-medicine, 24-hour nurse help lines,
and in-home patient monitoring.
Must be Licensed in NY and be able to attend occassional meetings
in NYC office
Remote - Clinical RN Quality Reviewer, Midtown Manhattan Office
Salary up to $95,000 with generous benefits - - Work From Home
100% remote or work from home role (maybe occasional meetings in
Clinical RN Quality Reviewer
Reports to Director of Quality and Health Plan Compliance. - Works
independently and with other departments and/or vendors to ensure
clinical potential quality issues are tracked, investigated, and
resolved in accordance with Plan requirements. - - Primarily
responsible for conducting post-service in-depth clinical reviews
(both inpatient and ambulatory medical services) in accordance with
accepted standards of care. - The overall goal is to improve
clinical service delivery and organizational processes.
Utilizes clinical expertise to conduct clinical case retrospective
reviews to determine deviation from standard of care or gaps in
care and presence of mandatory data elements. -
Document progress of investigation and findings in internal
databases and/or Excel spreadsheets.
Conduct clinical literature reviews and summarize findings.
Contact providers/facilities, as applicable, to obtain information
and/or medical records needed to conduct a comprehensive clinical
review of cases and final determinations.
Conduct chart reviews and audits both electronic and at medical
facilities and providers' offices.
Abstracts data relevant to review target.
Write succinct and targeted investigative summaries.
Write determination letters.
Maintain positive working relationships with internal and external
clinical/administrative personnel. -
Maintain confidentiality of all medical records, correspondence and
Effectively meets strict deadlines.
Participate in collection and analysis of data for clinical CDRLs
reports (i.e., monthly quality issue report, semi-annual AHRQ PSI
report, annual clinical quality management program report). -
Participate in collection, analysis and presentation of data for
Peer Review, Credentials Review and Quality Committees. -
Continuous Quality Improvement
Participate in continuous quality improvement activities/root cause
analysis to resolve identified quality issues and ensure forward
movement in beneficiary service delivery. -
Performs other duties as assigned or required. - Attends meetings
to achieve departmental/organizational goals and objectives.
Minimum 5 years of healthcare quality management experience and
minimum 5 years clinical nursing experience. - Quality
assurance/improvement experience in a managed health plan,
integrated health care system, or health care accreditation or
Ability to read, abstract and analyze medical records as well as
other clinical data.
Analytical mindset with excellent organizational and
Manages assigned caseload in accordance with established
Understanding of medical terminology, anatomy, physiology and
concepts of disease and health. - Fundamental knowledge of ICD-10,
CPT and HCPCS coding.
Understanding of Medicare, Medicaid and/or TRICARE. -
Proficient in Microsoft Office, including but not limited to Excel,
Outlook, PowerPoint and Word. - Experience in Access and Visio a
plus. - Ability and inclination to adopt technology to maximize
Decision making: - Identification of clinical quality issues as
evidenced by deviation from accepted standard of practice or gap in
care. - Ability to recommend corrective actions and/or
Current and unrestricted state RN license required
BA, BS, or BSN required
MSN, MS, MBA or MPH preferred
Quality management certification preferred
Keywords: RCM Health Care, New York , Clinical Quality Reviewer (RN) - Remote, Healthcare , New York, New York
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