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Quality and Pre/Post Review Nurse
Quality and Pre/Post Review Nurse Job Details Job Type
Full-time
Greensboro, NC • UM Care Management Description Job Summary
Under general direction, designs, coordinates and conducts reviews and quality assurance improvement activities for Utilization Management pre-authorizations including acute, post-acute, and member organization requests. Maintain data logs for monthly reporting including but not limited to home health, subrogation, and CMS Medicare Managed Care UM requirements and NCQA standards for Health Plans. Supports the philosophy and mission of HTA by facilitating performance improvement activities linked to the strategic plan. Scope of responsibilities requires knowledge of all authorization request types, methods of investigation and review, statistical analysis and reporting, performance measures, performance improvement techniques, and the frequent use of discretion, initiative, and sound clinical judgment.
Major Work Activities
Audits UM pre-certification records to ensure compliance with CMS and NCQA UM requirements and internal policies. Identifies trends, recommends corrective actions, and completes follow-up audits to ensure compliance. Review all request types as needed. Review high-risk, problem-prone pre/post service cases to ensure clinical documentation supports medical necessity prior to approval or payment of services. Identifies trends, recommends corrective actions, and completed follow-up audits to ensure compliance. Aids in preparation, presentation, and follow-up of all CMS and/or Health Plan Part C ODAG audits. Works collaboratively with the Health Plan compliance department to ensure all milestones/timelines are met with respect to Part C audit requirements. Assists UM leaders with the training of new UM staff Perform other duties as assigned
Requirements Minimum Qualifications
Required Education
BSN or equivalent education and/or work experience. Required Licensure/Regulatory
Annual Flu Vaccine COVID-19 Vaccine Current RN license in North Carolina Required Experience
4 years utilization management 2 years of quality assurance and improvement Required Knowledge, Skills, and Abilities
MS Word-basic knowledge Excel PowerPoint Statistical Analysis Preferred Qualifications
Preferred Licensure/Certification Regulatory
Certified Professional in Healthcare Quality (CPHQ) Preferred Experience
Health Plan UM experience
Time: Full time
Salary: Salary
Category: Clinical/pharmacy/quality
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Updated: 4/27/2022 1:03:38 PM
Job Contact:
Michael Abner
3364483122
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