Clinical Quality Assurance Nurse Auditor

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 

• Must hold and maintain an unencumbered Registered Nursing license.
• Must have Acute Care in hospital experience 
• Must have strong knowledge of medical terminology, anatomy and physiology, treatment protocols, medications and laboratory values.
• Must be able to add, subtract, multiply, and divide in all units of measure, using whole numbers and decimals; Ability to compute rates and percentages.
• Must be a qualified typist with a minimum of 40 W.P.M.
• Must be able to operate a general computer, fax, copier, scanner, and telephone.
• Must be knowledgeable of multiple software programs, including but not limited to Microsoft Word, Outlook, Excel, and the Internet.
• Must possess excellent skills in English usage, grammar, punctuation and style.
• Ability to follow instructions and respond to upper managements’ directions accurately.
• Demonstrates accuracy and thoroughness. Looks for ways to improve and promote quality and monitors own work to ensure quality is met.
• Must demonstrate exceptional communication skills by conveying necessary information accurately, listening effectively and asking questions where clarification is needed.
• Must be able to work independently, prioritize work activities and use time efficiently.
• Must be able to maintain confidentiality.
• Must be able to demonstrate and promote a positive team -oriented environment.
• Must be able to stay focused and concentrate with frequent interruptions.
• Must be able to work well under pressure and or stressful conditions.
• Must possess the ability to manage change, delays, or unexpected events appropriately.
• Demonstrates reliability and abides by the company attendance policy.
• Must maintain a professional and clean appearance at all times consistent with company standards.

About Us:

MES Solutions is a premier provider of independent medical examination and peer review services to the insurance, corporate, legal, and government sectors. Members of our credentialed medical panel conduct physical examinations or medical record reviews, delivering reports that assist clients in the resolution of automotive, disability, liability, and workers' compensation claims. MES has been providing services nationally since 1978 in accordance with the industry's highest standards of operating excellence and regulatory compliance.

MES is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, pregnancy, genetic information, disability, status as a protected veteran, or any other protected category under applicable federal, state, and local laws.

MES offers a fast-paced team atmosphere with competitive benefits (medical, vision, dental), paid time off, and 401k.