Registered Nurse - Quality Review
Prince George's County , MD | Healthcare
The Medical Quality Review Nurse independently performs clinical assessment functions of the review program as outlined by procedures, by conducting an initial screening for the Expert Reviewer/Medical Director. This position is responsible for investigating, examining, collecting and reporting all quality assurance issues to all staff at the facility.
Mon-Fri; 8:30a - 5:00 pm; NO WEEKENDS OR HOLIDAYS!!
- Performs comprehensive review of medical records to determine medical necessity, appropriateness of utilization level of care, and quality issues in accordance with pre-established criteria.
- Refers all potential adverse decisions to the Expert Reviewer/Medical Director or peer review.
- Identifies areas in criteria for potential modification and makes appropriate recommendations.
- Responsible for case specific or plan specific reports which includes but is not limited to technology systems. Enters data in various databases.
- Completes inquiry letters and final determination letters, case summaries, and provider performance reports within established timeframes and minimal oversight.
- Minimum 4-5 years of nursing experience
- Minimum 2-3 years of QR or QA experience
- Must have a valid, DC RN license
- Certified Professional in Healthcare Quality, Certified Professional in Health Management, Utilization Review, HEDIS chart audits, Healthcare Fraud Examiner or Compliance, HUGE PLUS!!
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NRI is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sex, sexual orientation, gender identity, age, status as a protected veteran, among other things, or status as a qualified individual with disability.