Job Description

Job Description

Job Description

Description:

Job Summary

Under the direct supervision of the Quality Assurance (QA) Director, the QA Nurse is responsible for conducting systematic audits of random Utilization Review (UR) cases to evaluate conformance with established guidelines; focus is on continuous quality improvement.

Essential Job Functions:

• Review and evaluate a random sample of completed UR cases daily against client specific requirements, contractual guidelines, Federal, State, and local regulations, and/or evidence-based practice using established parameters

• Review completed UR cases, prior to physician review, to identify errors or other opportunities for process improvement (i.e., use of correct clinical criteria, impediments to meeting TAT, clear and concise denial language, and criteria, etc.)

• Assist in the development of UR policies, procedures, training, and QA projects based on data collected from case reviews

• Assist in the collection and analysis of data against defined metrics

• Identify, track and trend discrepancies used to initiate and identify needed corrective action plans

• Responsible for high-quality, cyclical, professional QA reports free of grammar or spelling errors submitted to QA leadership

• Reports include at a minimum: total number of clarifications by UR nurse; categories of clarifications; percentages; comparison by month/quarter/year; and detailed performance improvement feedback

• Assist the QA Director to develop recommendations and follow-up activity based on root cause analysis with a focus on improved quality and efficiency

• Complete mandatory daily quota of audits with a high degree of accuracy: Reach and maintain a 15-20 average daily case load (combination of Peer Reviews and internal case/file reviews) within a specified timeframe with at least a 97% accuracy rate

• Communicate with QA Management on urgent issues, objectives and areas of needed improvement that require immediate attention

• Use logic and reasoning to interpret, analyze, and apply appropriate guidelines to medical-legal reviews and supporting clinical documentation

• Use evidenced-based research to review and comprehend medical/surgical modalities and imaging techniques to evaluate the standards of care identified.

• Apply pre-approved criteria and guidelines to validate medical necessity/appropriateness of treatment (e.g., ODG, MTUS, Milliman Care Guidelines, InterQual

• Maintain appropriate discretion with regard to confidential or sensitive information. Refrain from discussing with unauthorized people

• Maintain and expand professional competence in quality assurance and auditing

• Perform a low to moderate amount of research on a case-by-case basis

• Electronically file and retrieve corporate documents, records, and reports

• Participates in an interdisciplinary health care team environment

• Effectively communicate with internal and external customers (both orally and in writing)

• Compose and prepare correspondence

• Regular and consistent attendance required

• Other duties as assigned

Knowledge and Abilities Requirements:

• Must be extremely detail-oriented, quality driven; able to follow a detailed checklist systematically and develop own system as needed for organizing/tracking work processes

• Previous experience in UR or auditing in a managed care or healthcare setting

• Expert level written and verbal communication skills

• Proficiency in English with an aptitude for spelling and grammar

• Ability to work in high pressure, deadline driven environment with strong time management skills

• Must be capable of performing routine job functions with minimal supervision

• Strong ability to review clinical charts and documents for accuracy and completion

• Demonstrated ability to problem solve complex, multifaceted, situations

• Professional demeanor; ability to build rapport amongst staff and to provide constructive feedback

• Maintain a positive attitude and outstanding customer service while working closely internally with Nexus staff, panel physicians, and clients

• Must be able to give clear and accurate information with polite, persistent follow-up

• Ability to use Microsoft products; Word, Excel, PowerPoint, Outlook

• General Typing Skills at 45wpm

Education and Experience:

• Active RN licensure required; BSN is preferred

• 2-3 years of workers compensation management, clinical review & QA clinical review is required

License and Certification:

• Active & Unrestricted RN license required

Driving Essential: No

Position Demands:

This position requires sitting, bending, and stooping for up to 8 hours per day in an office setting. Ability to lift and move objects weighing up to 10 lbs. Ability to learn technical material. The person in this position needs to occasionally move about inside the office to access file cabinets, office machinery, etc. Must be able to operate a computer and other office productivity machinery such as a calculator, copy machine, printer, etc. The person in this position frequently communicates with guests, team members, and vendors and must be able to exchange accurate information.

Equal Employment Opportunity (Our EEO Statement):

The Company is a veteran-owned Company and provides Equal Employment Opportunities (EEO) to all Team Members and applicants for employment without regard to race, color, religion, sex, sexual orientation, gender (including gender identity), pregnancy, childbirth, or a medical condition related to pregnancy or childbirth, national origin, age, disability, genetic information, status as a covered veteran in accordance with applicable federal, state, and local laws, or any other characteristic or class protected by law and is committed to providing equal employment opportunities. The Company complies with applicable state and local laws governing non-discrimination in employment. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, promotion, discharge, pay, fringe benefits, membership, job training, classification, and other aspects of employment. Team Members who believe they are the victims of discrimination should immediately report the concern to their Supervisor and Human Resources Department. Discrimination and harassment will not be tolerated.

We are committed to creating an inclusive environment for all Team Members and applicants. We value the unique skills and experiences that veterans bring to our team and encourage veterans to apply.

Disclaimer:

The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of our personnel. All company team members may be required to perform duties outside of their normal responsibilities from time to time, as needed.

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