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About the Role
This role independently ensures clinical quality issues are tracked, investigated, and resolved according to TRICARE and Plan requirements. The primary responsibility is conducting post-service clinical reviews to improve clinical service delivery.
Responsibilities
- Conduct clinical case retrospective reviews to determine deviation from standard of care or gaps in care.
- Document progress of investigation and findings in internal databases and/or Excel spreadsheets.
- Conduct clinical literature reviews and summarize findings.
- Contact providers/facilities to obtain information and/or medical records for comprehensive clinical reviews.
- Conduct chart reviews and audits (electronic and at facilities/offices) and abstract relevant data.
- Write succinct and targeted investigative summaries and quality review determination letters.
- Develop and manage collaborative relationships with internal/external stakeholders and vendor staff.
- Maintain confidentiality of all medical records, correspondence, and related documents.
- Meet strict deadlines.
- Identify and report suspected fraudulent activity.
- Participate in the collection and analysis of data for clinical CDRLs reports.
- Participate in the collection, analysis, and presentation of data for Peer Review, Credentials Review, and Quality Committees.
- Evaluate data for trends.
- Participate in continuous quality improvement activities/root cause analysis to resolve identified quality issues.
- Cross-train and perform other duties as assigned or required within the Quality Department.
- Attend meetings to achieve departmental/organizational goals and objectives.
Requirements
- 1-3 years of healthcare quality management experience.
- 1-3 years of clinical nursing experience.
- Quality assurance/improvement experience in a managed health plan, integrated health care system, or health care accreditation or regulatory agency.
- Ability to read, abstract, and analyze medical records and other clinical data.
- Analytical mindset with excellent organizational and problem-solving skills.
- Ability to work both independently and as a team member.
- Strong project management skills.
- Intermediate statistical analysis expertise including interpretation of data.
- Effective verbal and written communication skills.
- Ability to work collaboratively with different teams and team members.
- Manages assigned caseload in accordance with established performance metrics.
- Excellent customer service skills.
- Understanding of medical terminology, anatomy, physiology, and concepts of disease and health.
- Fundamental knowledge of ICD-10, CPT, and HCPCS coding.
- Understanding of Medicare, Medicaid, and/or TRICARE.
- Proficient in Microsoft Office (Excel, Outlook, PowerPoint, Word).
- Experience in Access and Visio is a plus.
- Ability and inclination to adopt technology to maximize efficiency.
- Ability to identify clinical quality issues and recommend corrective actions and/or sanctions.
Skills
- Clinical expertise
- Data analysis
- Report writing
- Project management
- Statistical analysis
- Verbal communication
- Written communication
- Collaboration
- Customer service
- Microsoft Office Suite
- Technology adoption
Location
- Remote
- In Office
Work Type
- Remote
- In Office
- Hybrid
Experience Level
- 1-3 years
Education Level
- Current and unrestricted state RN or LPN/LVN license required
- BA, BS, or BSN preferred
Salary/Compensations
- LPN/LVN $80,000 – $85,000.00
- RN $107,000.00 - $115,000.00
Benefits
- Medical coverage through UnitedHealthcare/Oxford with no deductible for in-network services.
- Vision coverage through UnitedHealthcare Vision.
- Dental benefits through MetLife.
- Basic life and disability insurance provided at no cost.
- Commuter benefits.
- Tuition reimbursements.
- 401(k)-retirement plan with an immediate employer match that is fully vested from day one.
- Generous time off package (vacation, 10 paid holidays, 3 personal days).
- Comprehensive Employee Assistance Program.
- Exclusive discounts through Working Advantage.
About the Company
- SVCMC, Inc. provides a robust benefits package.
Equal Opportunity
- SVCMC IS AN EQUAL OPPORTUNITY EMPLOYER - ALL QUALIFIED APPLICANTS WILL RECEIVE CONSIDERATION FOR EMPLOYMENT WITHOUT REGARD TO VETERAN STATUS, DISABILITY, OR OTHER CHARACTERISTICS PROTECTED BY LAW.