*                                                                                Position Description:* * Quality Assurance Review Nurse*

　　Reporting to the Director, the QA Review Nurse will provide professional assessment, planning, coordination, implementation and reporting of complex clinical data and support the medical review operations of Provider Resources, Inc. (PRI).  The nurse position will perform comprehensive medical record to make utilization, quality of care, and standards of care determinations based on evidence-based standards of care, applicable coverage policies, and utilization and practice guidelines.

　　Responsibilities

　　Understand and represent PRI's mission, vision, and values to all internal and external customersInteract with government and private sector clients, partners, and PRI staff in a professional and accountable manner, and as a representative of PRI managementEngage clients in appropriate communication that manages client expectations and builds a collaborative relationship with the clientDevelops and maintains a detailed project schedule which includes administrative tasks involved in the projectProactively manages and coordinates activities to ensure timeliness of deliverables to exceed contractual obligationsInteract with project team members in order to successfully fulfill contract obligations with the highest quality and in a timely manner meeting PRITM** 's ISO requirementsInstills integrity throughout the organization via active participation in ISO requirements including but not limited to timely submission of Corrective Action Plans for all matters in which either PRITM** standards and/or corporate contract standards have not been met. Communicating outcomes to team members to ensure a positive, open, environment which mitigates risk and achieves a culture of Continuous Quality ImprovementScreen cases upon intake for referral to peer reviewersPerform medical record review in accordance with all State, Federal and/or commercially mandated regulationsPerforms QA for non-physician reviews and supports PMMaintain compliance with all regulation changes as they impact medical and utilization review practicesAnalyze patient records and participate in interdisciplinary collaboration with PRI staff and all recognized teaming partners and/or subcontractorsDocument all review information into the appropriate Medical Review form, report and/or system.  Communicate these report results to the appropriate supervisorUtilize electronic health information imagingUtilize Internet and Intranet resources for applicable research, e.g., evidence-based standards of care guidelines, quality measures, etc.Make clinical judgments based on evidence-based standards of care, review criteria and nursing practice guidelines when applicableUnderstand and represent PRI's mission, vision, and values to all internal and external customersPerform other duties as requested

　　Requirements:

　　Bachelor's Degree in Nursing (BSN), MSN preferredRequire a minimum of three (3) years' experience in a supervisory/managerial role in the health insurance industryExtensive experience performing medical review, utilization/quality assurance reviews, and application of nursing standards of careMust be a Registered Nurse (RN) with an active license in state of residenceBroad knowledge base of health care delivery and case management within a managed care environmentKnowledge of utilization review process, OIG, CMS, RAC, and all other regulatory agencies related to utilization management.Comprehensive knowledge of medical necessity standards, levels of care, inpatient and outpatient statusExtensive knowledge of state and federal healthcare regulations and policies,Two or more years' experience in medical/utilization revie and quality improvement/quality managementExcellent writing and communication skillsKnowledgeable of quality measures and National Quality StrategyKnowledgeable of ICD-9-CM/ICD-10-CM, CPT-4 and HCPCS coding desirableKnowledge of Microsoft office suite such as Outlook, Access, Excel and WordCertification in quality improvement/quality management, and/or utilization management/review preferredOne year or more of utilizing InterQual and/or Milliman guidelines is preferredMust have no adverse actions pending or taken against him/her by any State or Federal licensing board or programMust have no conflict of interest (COI) as defined in 1154(b)(1) of the Social Security Act (SSA)Ability to obtain and maintain U.S. Government Security ClearancePreference will be given to individuals who reside in, or are willing to relocate to, a recognized HUBZone area.  (Go to http://map.sba.gov/hubzone/maps/ for more information).

　　FLSA status:  Exempt

　　Contract Compensation Plan

　　PRI is an equal employment opportunity employer.  All qualified applicants including Disability/Vets or other qualified applicants will receive consideration for employment without regard to race, color, religion, gender, national origin, disability status, protected veteran status or any other characteristic protected by law.

　　Qualified candidates may apply by clicking, "Apply Now". Next, submit your resume. You may complete a cover letter on the following screen. *You must contact the employer via one of the methods listed on the screen after clicking "Apply for this job". * Please be sure to identify PA CareerLink as your referral source.