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

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  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. -
  
  
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  Document progress of investigation and findings in internal databases and/or Excel spreadsheets.
  
  
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  Conduct clinical literature reviews and summarize findings.
  
  
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  Contact providers/facilities, as applicable, to obtain information and/or medical records needed to conduct a comprehensive clinical review of cases and final determinations.
  
  
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  Conduct chart reviews and audits both electronic and at medical facilities and providers' offices.
  
  
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  Abstracts data relevant to review target.
  
  
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  Write succinct and targeted investigative summaries.
  
  
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  Write determination letters.
  
  
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  Maintain positive working relationships with internal and external clinical/administrative personnel. -
  
  
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  Maintain confidentiality of all medical records, correspondence and related documents.
  
  
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  Effectively meets strict deadlines.
  
  
  
  Reporting
  
  
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    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). -
    
    
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    Participate in collection, analysis and presentation of data for Peer Review, Credentials Review and Quality Committees. -
    
    
    
    Continuous Quality Improvement
    
    
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      Participate in continuous quality improvement activities/root cause analysis to resolve identified quality issues and ensure forward movement in beneficiary service delivery. -
      
      
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      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
      
      
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        Ability to read, abstract and analyze medical records as well as other clinical data.
        
        
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        Analytical mindset with excellent organizational and problem-solving skills.
        
        
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        Manages assigned caseload in accordance with established performance metrics.
        
        
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        Understanding of medical terminology, anatomy, physiology and concepts of disease and health. - Fundamental knowledge of ICD-10, CPT and HCPCS coding.
        
        
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        Understanding of Medicare, Medicaid and/or TRICARE. -
        
        
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        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
        
        
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        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
        
        
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          Current and unrestricted state RN license required
          
          
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          BA, BS, or BSN required
          
          
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          MSN, MS, MBA or MPH preferred
          
          
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          Quality management certification preferred
          
          

Keywords: RCM Health Care, New York , Clinical Quality Reviewer (RN) - Remote, Healthcare , New York, New York