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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
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)
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.
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.


    • 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 regulatory agency.

        • 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.


          • 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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