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Quality and Pre/Post Review Nurse

Quality and Pre/Post Review Nurse
Job Details
Job Type


Greensboro, NC • UM Care Management
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

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
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

Updated: 4/27/2022 1:03:38 PM

Job Contact:
Michael Abner

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7800 McCloud Road
Greensboro, NC 27409