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Quality Management Nurse Consultant

US Tech Solutions

Role overview

Qualifications

  • 3 years of clinical experience required
  • Experience with Medcompass
  • Prior authorization utilization experience
  • RN with current unrestricted state licensure

Responsibilities

  • Reviews documentation and evaluates potential quality of care issues based on clinical policies and benefit determinations
  • Considers all documented system information to develop a determination or recommendation
  • Data gathering requires navigation through multiple system applications
  • Evaluates documentation/information to determine compliance with clinical policy, regulatory and accreditation guidelines

About the company

US Tech Solutions logo

US Tech Solutions

Staffing & Recruiting

USTECH SOLUTIONS is the largest privately owned diversity workforce partner with a global footprint. For 20+ years, we have partnered with leading MSPs and some of the world’s largest enterprises to deliver a flexible workforce. We serve Fortune 500 giants and growing businesses alike, reinventing the role of humans in a digital workforce. ‘Reinventing Human’ is about connecting you with top talent and seamlessly integrating new hires into your programs through our next gen AI powered Talent platforms. As the largest private diversity supplier in the US, we champion inclusion and unlock hidden potential. We work with leading MSPs and are a trusted strategic partner to the world’s top brands. At USTECH SOLUTIONS, we're inverting the talent hiring pyramid by offering a range of solutions from curated talent pools, workforce management services, and IT services resourcing to IC compliance. Our legacy and close affinity to the computing industry has equipped us with the expertise and vision to provision AI platform solutions that help organizations to innovate faster. Considering Statement of Work? Meet US Tech Digital (ustechdigital.com). We're helping businesses achieve digital leadership through our tailored SOW solutions, utilizing market-leading technology products and our proprietary in-house developed platform solutions. Explore our full range of services and solutions by visiting our website: ustechsolutions.com

Company details

Company typeLarge
IndustryStaffing & Recruiting
Company size1001 - 5000

Links

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Job description

Job Description:
  • Responsible for the review and evaluation of clinical information and documentation.
  • Reviews documentation and interprets data obtained from clinical records or systems to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider issues.
  • Independently coordinates the clinical resolution with internal/external clinician support as required.
 
Responsibilities:
  • Reviews documentation and evaluates potential quality of care issues based on clinical policies and benefit determinations.
  • Considers all documented system information as well as any additional records/data presented to develop a determination or recommendation.
  • Data gathering requires navigation through multiple system applications.
  • Staff may be required to contact the providers of record, vendors, or internal Healthcare departments to obtain additional information.
  • Evaluates documentation/information to determine compliance with clinical policy, regulatory and accreditation guidelines.
  • Accurately applies review requirements to assure case is reviewed by a practitioner with clinical expertise for the issue at hand.
  • Commands a comprehensive knowledge of complex delegation arrangements, contracts, clinical criteria, benefit plan structure, regulatory requirements, company policy and other processes which are required to support the review of the clinical documentation/information.
  • Pro-actively and consistently applies the regulatory and accreditation standards to assure that activities are reviewed and processed within guidelines.
  • Condenses complex information into a clear and precise clinical picture while working independently.
 
Experience:
  • 3 years of clinical experience required.
  • Must have experience with Medcompass
  • Must have prior authorization utilization experience.
  • Managed Care/Medicare experience preferred.
 
Skills:
  • MUST HAVE MEDCOMPASS or ASSURECARE exp.
  • MUST HAVE MANAGED CARE exp and Medicare/Medicaid knowledge.
  • MUST HAVE UM experience, inpatient utilization management review.
  • MUST HAVE 1 YEAR OF UTILIZATION MANAGEMENT EXP, pref. knowledge of Milliman/MCG.
  • MUST HAVE 6 months of Prior Authorization.
 
Education:
  • RN with current unrestricted state licensure
 
About US Tech Solutions:
US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To know more about US Tech Solutions, please visit www.ustechsolutions.com.
 
US Tech Solutions is an Equal Opportunity Employer.  All qualified applicants will receive consideration for employment without regard to race, colour, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

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Marcus Rivera

Chief Revenue Officer

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