Health Management Systems, Inc. UR Nurse Reviewer in Charlestown, Massachusetts

The Nurse Reviewer is responsible for performing clinical reviews of medical information and quality assurance as defined by review methodologies specific to the contract for which services are being provided.

Essential Functions:

  • Performs clinical and medical reviews, data collection and database entry.

  • Assigns case reviews by identifying the issues for review and the specialty of the physician reviewer necessary to complete the peer matched review.

  • Provides supporting reference documentation to the reviewer.

  • Applies state laws during the Quality Assurance process.

  • Interacts with physician reviewers.

  • Assists in the transcription of physician reviews by editing and formatting, as needed.

  • Assures that all work is completed within contractual deadlines and that all components of the completed review are present.

  • Delivers final product to the client per client specific contractual guidelines.

  • Communicates with appropriate parties regarding review (enrollee, authorized representative, health plan representative, facility and state department of insurance).

  • Receives requests for precertification of procedures via telephone, fax, or Web.

  • Utilizes clinical expertise to approve services or refer requests to a physician for review.

  • Oversees referrals to and from physician review.

  • Formats and edits approval and denial letters.

  • Performs retrospective chart review per contract specifications.

  • Prepares letters to summarize retrospective review activity.

  • Evaluates, identifies, and reports on, quality of care issues.

  • Communicates with health care professionals as a liaison regarding contract specifications and escalates issues as appropriate.

  • Participates on quality improvement teams.

  • Facilitates quality improvement plan development and implementation as requested, both internally and with external customers.

  • Participates in the project data analysis, reporting, and feedback processes.

Other Functions:

  • Performs other functions as assigned

Knowledge, Skills and Abilities:

  • Ability to work proficiently with Microsoft Word, Excel, and Power Point.

  • Ability to analyze and evaluate medical information.

  • Ability to provide good customer service skills.

  • Ability to medically review; chart audits, and quality improvement processes.

  • Ability to perform well in team environment, with staff at all levels, to achieve business goals.

  • Ability to function under pressure and with deadline oriented project demands as well as manage multiple initiatives.

  • Ability to apply existing knowledge of health care marketplace including commercial and government insurance health plan organizations and HIPAA guidelines with their associated security requirements.

  • Ability to work independently to meet predefined production and quality standards

  • Working knowledge in and successful application of basic level of health care data analysis and clinical review.

Work Conditions and Physical Demands:

  • Primarily sedentary work in a general office environment

  • Ability to communicate and exchange information

  • Ability to comprehend and interpret documents and data

  • Requires occasional standing, walking, lifting, and moving objects (up to 10 lbs.)

  • Requires manual dexterity to use computer, telephone and peripherals

  • May be required to work extended hours for special business needs

  • May be required to travel at least 10% of time based on business needs

Certifications: (Required/Desired)

  • Unrestricted RN license required

Minimum Education:

  • Associate’s degree or diploma (Nursing program) required; Bachelor's degree preferred

Minimum Related Work Experience:

  • 3 years clinical experience required

  • 1 year utilization review experience preferred

Nothing in this job description restricts management’s right to assign or reassign duties and responsibilities to this job at any time.

Title: UR Nurse Reviewer

Location: Massachusetts-Charlestown

Requisition ID: 170010RG