Nurse Case Manager/QA Specialist
6 days left
- Career Level
- Not Specified
York Risk Services Group is a premier provider of insurance, risk management, alternative risk, pool administration and claims management solutions to clients across hundreds of industries. Recently named by Forbes as one of "America's Best Midsized Companies Two Years in a Row" We firmly believe that our employees drive the success of the company. With success in mind as the ultimate goal, we strive to create and provide an environment that offers challenging, stimulating and financially rewarding opportunities.
- Review and evaluate case decisions applying quality assurance criteria, state regulations, and URAC requirements;
- Ensure accuracy and completeness of documentation;
- Communicate effectively any inconsistencies and/or inaccuracies;
- Compile and summarize data for presentation;
- Assist in the development and implementation of appropriate action plans to approve and assure compliance with regulatory requirements;
- Participate and understand scope of responsibility in all ongoing QA Projects;
- Adheres to quality assurance standards; and
- Maintains objectivity and confidentiality.
- The Q/A nurse reports to the Compliance Manager.
- Must have an unrestricted RN.
- 2 years clinical experience.
- Excellent grammar skills, critical thinking skills, and ability to manage time efficiently and meet stringent time frames.
- Must be proficient in PC skills. (MS Word, Excel, and Outlook.)
- Must be knowledgeable of current URAC and multi-state regulations related to Workers' Compensation.
- Must be knowledgeable of quality assessment and assurance procedures.
- Must possess knowledge of medical terminology, medical records, and ICD 10.
ROUTINE DECISIONS AND FORMAL POLICY SETTING:
Decisions routinely made include:
- No formal responsibility. Policies associated with the jobs purpose and essential responsibilities are set by others.