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Clinical Quality Reviewer (RN) - Remote

Company: RCM Health Care
Location: New York
Posted on: January 27, 2023

Job Description:

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
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Remote - Clinical RN Quality Reviewer, Midtown Manhattan Office
Salary up to $95,000 with generous benefits - - Work From Home Role!!
100% remote or work from home role (maybe occasional meetings in office)
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Clinical RN Quality Reviewer
JOB SUMMARY
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.
RESPONSIBILITIES
Clinical Review



  • 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 related documents.


  • Effectively meets strict deadlines.



    Reporting



    • 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.



        EXPERIENCE
        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 regulatory agency.
        Skills/Competencies



        • Ability to read, abstract and analyze medical records as well as other clinical data.


        • Analytical mindset with excellent organizational and problem-solving skills.


        • Manages assigned caseload in accordance with established performance metrics.


        • 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 efficiency


        • 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 sanctions.



          Education/Certifications/License



          • 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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