Required Function 1:
The Nurse Reviewer is responsible for performing clinical reviews of medical information and quality assurance as defined by review methodologies specific to the contract for which services are being provided.
Required Function 2:-
Performs clinical and medical reviews, data collection and database entry.- Assigns case reviews by identifying the issues for review and the specialty of the physician reviewer necessary to complete the peer matched review.- Provides supporting reference documentation to the reviewer.- Applies state laws during the Quality Assurance process.- Interacts with physician reviewers.- Assists in the transcription of physician reviews by editing and formatting, as needed.- Assures that all work is completed within contractual deadlines and that all components of the completed review are present.- Delivers final product to the client per client specific contractual guidelines.- Communicates with appropriate parties regarding review (enrollee, authorized representative, health plan representative, facility and state department of insurance).- Receives requests for precertification of procedures via telephone, fax, or Web.- Utilizes clinical expertise to approve services or refer requests to a physician for review.- Oversees referrals to and from physician review.- Formats and edits approval and denial letters.- Performs retrospective chart review per contract specifications.- Prepares letters to summarize retrospective review activity.- Evaluates, identifies, and reports on, quality of care issues.- Communicates with health care professionals as a liaison regarding contract specifications and escalates issues as appropriate.- Participates on quality improvement teams.- Facilitates quality improvement plan development and implementation as requested, both internally and with external customers.- Participates in the project data analysis, reporting, and feedback processes.
Required Function 3:-
Unrestricted RN license required
Minimum Education:- Associate’s degree or diploma (Nursing program) required; Bachelor's