Clinical Quality Review Nurse Jobs

ICD10 HCS-D certification strongly preferred.

Home Care Home Base software experience a plus!

Strong computer and technology skills required.

About Trinity Health At Home

Degree: Bachelor's preferred. Associate nursing degree considered if successfully demonstrated career progression and meets and exceeds performance expectations.

Ability to consistently demonstrate alignment to the Mission, Vision and Values, Organizational Code of Ethics and adhere to the Compliance Program.

Conduct periodic needs assessments to identify knowledge gaps

Requires a bachelors degree or equivalent experience

Requires at least 7 years of prior relevant experience

Requires 3-5 plus years hands-on clinical experience across a variety of specialties and settings

Preferred Nursing Informatics experience and/or degree

Strong verbal/written communication and organizational skills

Experience with utilization management systems or clinical decision making tools such as Medical Coverage Guidelines (MCG) or InterQual.

Working collaboratively with the audit team to identify and obtain approval for particular vulnerabilities and/or cases subject to potential abuse

Work in partnership with our clients, CMD colleagues, and other contractors on improving medical policies, provider education, and system edits

Strong preference for experience performing utilization review for an insurance company, Tricare, MAC or organizations performing similar functions

Experience with ICD-9, ICD-10, CPT-4 or HCPCS coding.

Knowledge of insurance programs program, particularly the coverage and payment rules.

A range of health, dental, vision, prescription and life insurance benefits

Opportunities and support for continued education including tuition reimbursement

Three years acute care clinical experience

One (1) to three (3) years clinical quality assurance/quality improvement experience preferred; previous peer review experience preferred.

Demonstrated proficiency with personal computers, including data entry, word processing and spreadsheet applications required; MS Office Suite required.

Demonstrated ability to manage multiple competing priorities required.

Knowledge of managed care processes.

Organizational skills and ability to meet deadlines and manage multiple priorities.

Proficient with Milliman Care Guidelines (MCG) management.

5 years combine knowledge of healthcare processes.

Verbal and written communication skills to include interfacing with staff across organizational lines plus interfacing with members and providers.

PC experience to include Microsoft Word, Access, and Excel.

Experience with utilization management systems or clinical decision making tools such as Medical Coverage Guidelines (MCG) or InterQual.

Working collaboratively with the audit team to identify and obtain approval for particular vulnerabilities and/or cases subject to potential abuse

Work in partnership with our clients, CMD colleagues, and other contractors on improving medical policies, provider education, and system edits

Strong preference for experience performing utilization review for an insurance company, Tricare, MAC or organizations performing similar functions

Experience with ICD-9, ICD-10, CPT-4 or HCPCS coding.

Knowledge of insurance programs program, particularly the coverage and payment rules.

Ongoing management of provider education on quality HEDIS measures

5+ years RN experience in performing UM, CM responsibilities working with the Medicaid population

Send monthly emails to providers notifying them that their latest PCOR is available to view and manage in Practice Assist

Developed provider education on the PPC and WCC measures in hopes to have better compliance in the future

3+ years of clinical nursing experience

Experience with presenting presentations and public speaking

Notify respective management of "Red Flag Events", as noted within departmental documentation, caused by colleagues

Assist in creation and rollout of education and training materials for Credentialing Department needs

Excellent verbal and written communication skills

Expert level understanding of credentialing and licensure requirements

Intermediate knowledge of Microsoft Word, Outlook, Excel

Computer keyboard proficiency and internet navigation skills required

Master’s degree in nursing, education or related field preferred.

Sign-on Bonuses OR Student Loan Assistance for clinical staff

FREE Online RN to BSN and MSN degree programs!

Tuition Reimbursement for all full and part-time staff

Dependent Tuition Reimbursement for clinical staff!

Affordable medical, dental and vision coverage for employee and family members

Medicare Part B Appeals experience preferred.

Job Family: Medical and Clinical

Conducts investigations and reviews of member and provider grievances and appeals.

Generates appropriate written correspondence to providers, members, and regulatory entities.

Ensures that appeals and grievances are resolved timely to meet regulatory timeframes.

Adapts to a wide variety of medical review topics in Part B appeals.

Medicare Part B Appeals experience preferred.

Job Family: Medical and Clinical

Conducts investigations and reviews of member and provider grievances and appeals.

Generates appropriate written correspondence to providers, members, and regulatory entities.

Ensures that appeals and grievances are resolved timely to meet regulatory timeframes.

Adapts to a wide variety of medical review topics in Part B appeals.

3-5 years’ minimum experience in Occupational health settings, hospital, and outpatient nursing

Career development with an international company where you can grow the career you dream of.

Free medical coverage for employees* via the Health Investment Plan (HIP) PPO

An excellent retirement savings plan with high employer contribution

Provide subject matter expertise in executing Drug Testing Services across Workplace Solutions broad customer base.

Interpret and report results of Workplace clients consistent with Workplace Solutions written Standard Operating Procedures.

Develops and conducts various audit activities to assess adherence with care management, organizational, and accreditation standards/expectations.

Expertise in research methodology, data analysis, database management, and outcomes studies.

Understanding the core elements of case management, care coordination, transitions of care, and related processes relevant to the organization's dynamic services.

Processes and utilizes data to analyze, monitor, and report performance using various databases and information systems (e.g., LTSS, CARMA, CRISP).

Develops and utilizes dashboards, reports, infographics, presentations, and/or conducts 1:1 and group interactions to share information (as needed).

Registered nurse with an active, unencumbered license in the State of Maryland.

If you are relying on your education to meet qualification requirements:

Analyzes VASQIP/QM data and recommends action for the purpose of improving patients care management.

Participates in local and national studies for the purpose of improving patient care management.

Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).

Nurse I Level I - An Associate Degree (ADN) or Diploma in Nursing, with no additional nursing practice/experience required.

You will be evaluated for this job based on how well you meet the qualifications above.

Experience with utilization management systems or clinical decision-making tools such as Medical Coverage Guidelines (MCG) or InterQual.

Experience with ICD-9, ICD-10, CPT-4 or HCPCS coding.

Knowledge of insurance programs program, particularly the coverage and payment rules.

Excellent written and verbal communication skills.

Ability to manage multiple tasks including desk audits and claims review.

Minimum of three years diversified nursing experience providing direct care in an inpatient or outpatient setting.

5 – 10 years of previous experience in long term care in a nursing management role.

Participates in the development of educational materials and staff training programs relative to long term care.

Participates in the compilation and completion of quarterly and other reports prepared for the HHC Board of Directors’ Planning Committee.

May attend HHC Planning Committee meetings as assigned to represent the Long Term Care Department or to present a special report.

Assists in the completion and follow up of any requests or directives resulting form the Planning Committee meetings as assigned.

Attends community and professional association functions and meetings representing HHC Long Term Care division as requested.

This position is responsible for quality management/quality improvement activities with Care

Sandhills Center is a Local Management Entity-Managed Care Organization (LME-MCO) serving

Coordination/Case Management, Population Health, Community Relations, Pharmacy

3+ years of quality improvement or healthcare related experience

responsible experience in gathering, editing, and analyzing data or healthcare

and three years of experience as indicated above.

Time management skills; establishing priorities and accomplishing tasks in an accurate and timely basis.

Strong healthcare claims processing expertise and medical terminology knowledge.

Oral and written communication skills.

It's fun to work in a company where people truly BELIEVE in what they're doing!

We're committed to bringing passion and customer focus to the business.

Normal busy office environment. Moderate noise (examples: business office with computers and printers, light traffic)

Identify and manage actions needed to installations up to the Lumio standard

At least 1 years of solar installation experience

At least 2 years of experience in PV design

At least 1 years of experience as a solar Inspection technician

Experience with solar inverters installation and operations

Experience with battery installation and operations