Clinical Quality Assurance Nurse Auditor (28835)

Are you a Registered Nurse (RN)  looking to move away from the bedside while still utilizing your clinical skills AT HOME? With Acute Care experience?

ExamWorks is looking for detail-oriented and motivated candidates  *REMOTE* Clinical Quality Assurance Nurse Auditor to join the team!

The standard schedule for this role is: Monday-Friday  8am-5pm 

The Clinical Quality Assurance Nurse Auditor is responsible for evaluating clinical information received from Organ Procurement Organization auditing hospital records received. This position ensures reports are completed with highest quality and integrity and that all work is in full compliance with client contractual agreements, regulatory agency standards and/or federal and state mandates. This position is required to handle quality assurance questions and provide overall support to the Quality Assurance Department.

• Evaluates clinical information received, writes and/or reviews various reports including Medical Record Reviews, Medical Record Chronologies, Provider Bill Reviews, Coding Reviews, Hospital Bill Reviews, List of Missing Records, Medical Bill Apportionments, Mock Billing Invoice and Medical Summary Statements.
• Performs quality assurance review of peer review reports, correspondences, addendums or supplemental reviews.
• Ensures clear, concise, evidence-based rationales have been provided in support of all recommendations and/or determinations.
• Ensures that all client instructions and specifications have been followed and that all questions have been addressed.
• Ensures each review is supported by clinical citations and references when applicable and verifies that all references cited are current and obtained from reputable medical journals and/or publications.
• Ensures the content, format, and professional appearance of the reports are of the highest quality and in compliance with company standards.
• In IME or Peer Review cases, ensures the appropriate board specialty has reviewed the case in compliance with client specifications and/or state mandates and is documented accurately on the case report.
• Verifies that the peer reviewer has attested to only the fact(s) and that no evidence of reviewer conflict of interest exists.
• Ensures the provider credentials and signature are adhered to the final report.
• Identifies any inconsistencies within the report and contacts the Peer Reviewer to obtain clarification, modification or correction as needed.
• Contacts appropriate person to recover any missing documentation or verify charges.
• Assists in resolution of customer complaints and quality assurance issues as needed.
• Ensures all federal ERISA and/or state mandates are adhered to at all times.
• Provides insight and direction to management on consultant quality, availability and compliance with all company policies and procedures and client specifications.
• Promote effective and efficient utilization of company resources.
• Participate in various continuing education requirements and or training activities.

EDUCATION AND/OR EXPERIENCE

Bachelor degree in nursing or related field; or minimum five years related experience; or equivalent combination of education and experience. Experience with medical terminology, medications, medical specialties and treatment protocols required. Experience in the insurance industry preferred.

CERTIFICATES, LICENSES, REGISTRATIONS

Registered Nursing license required.

QUALIFICATIONS