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Form of workExamWorks is seeking a Clinical Quality Assurance Nurse Auditor to join the team! If you are a RegisteredNurse, detail-oriented and enjoy proofreading, this may be perfect for you!
This position is 100%remote. It is highly preferred that candidates are located in PST, MST,or CST.
The Clinical Quality Assurance Nurse Auditor is responsible for evaluating clinical information received from various healthcare providers and writes various reports based on the clinical information 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.
Responsibilities
- 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
Qualifications
- RN licensure required
- Bachelor degree in nursing or related field; or 5+ 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 but not required
- Must possess excellent skills in English usage, grammar, punctuation and style
- Must be able to maintain confidentiality
ABOUT US:
ExamWorks is a leading provider of innovative healthcare services including independent medical examinations, peer reviews, bill reviews, Medicare compliance, case management, record retrieval, document management and related services. Our clients include property and casualty insurance carriers, law firms, third-party claim administrators and government agencies that use independent services to confirm the veracity of claims by sick or injured individuals under automotive, disability, liability and workers' compensation insurance coverages.
ExamWorks, LLC is an Equal Opportunity Employer and affords equal opportunity to all qualified applicants for all positions without regard to protected veteran status, qualified individuals with disabilities and all individuals without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age or any other status protected under local, state or federal laws.
Equal Opportunity Employer - Minorities/Females/Disabled/Veterans
Employment Type: OTHER
