Clinical Quality Assurance Nurse Auditor

October 24

🍂 Massachusetts – Remote

Although this job is listed in Massachusetts, this company may be open to hiring remote in other states.

💵 $34 - $39 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔧 QA Engineer (Quality Assurance)

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MES Solutions

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Healthcare Insurance • B2B • Government

MES Solutions is a provider of independent medical evaluation and peer review services for the claims and risk-management community. The company coordinates Independent Medical Examinations (IMEs), record retrieval and record reviews, peer review services, physician credentialing, and fitness-for-duty and disability assessment support. Its clients include insurers, third-party administrators, self-insured employers, government agencies, and attorneys across auto, disability, liability, workers' compensation, and group health markets, and it emphasizes compliance with HIPAA, HITECH, and HITRUST.

201 - 500 employees

Founded 1978

⚕️ Healthcare Insurance

🤝 B2B

🏛️ Government

📋 Description

• Evaluate clinical information received, write and/or review various reports including, but not limited to, Medical Record Reviews, Medical Record Chronologies, Provider Bill Reviews, Coding Reviews, Hospital Bill Reviews, List of Missing Records, Medical Bill Apportionments, Mock Billing Invoice and Medical Summary Statements. • Perform quality assurance review of peer review reports, correspondences, addendums or supplemental reviews. • Ensure clear, concise, evidence-based rationales have been provided in support of all recommendations and/or determinations. • Ensure that all client instructions and specifications have been followed and that all questions have been addressed. • Ensure each review is supported by clinical citations and references when applicable and verify that all references cited are current and obtained from reputable medical journals and/or publications. • Ensure the content, format, and professional appearance of the reports are of the highest quality and in compliance with company standards. • Ensure the appropriate board specialty has reviewed the case in compliance with client specifications and/or state mandates and is documented accurately on the case report. • Verify that the reviewer has attested to only the facts and that no evidence of reviewer conflict of interest exists. • Ensure the provider credentials and signature are adhered to the final report. • Identify any inconsistencies within the report and contacts the Reviewer to obtain clarification, modification or correction as needed. • Contact the appropriate person to recover any missing documentation or verify charges. • Assist in resolution of customer complaints and quality assurance issues as needed. • Ensure all federal ERISA or state mandates are adhered to at all times. • Provide insight and direction to management on consultant quality, availability and compliance with all company policies and procedures and client specifications. • Promote effective and efficient utilization of company resources. • Participate in various continuing education requirements and or training activities. • Perform other duties as assigned.

🎯 Requirements

• Bachelor/Associate degree in nursing or related field; or minimum five years related experience; or equivalent combination of education and experience. • Experience with medical terminology, medications, medical specialties and treatment protocols required. • Experience in the insurance industry preferred. • Must have strong knowledge of medical terminology, anatomy and physiology, medications and laboratory values. • Must be a qualified typist with a minimum of 40 W.P.M. • Must be able to operate a general computer, fax, copier, scanner, and telephone. • Must be knowledgeable of multiple software programs, including but not limited to Microsoft Word, Outlook, Excel, and the Internet. • Must possess excellent skills in English usage, grammar, punctuation and style. • Ability to follow instructions and respond to upper managements’ directions accurately. • Demonstrates accuracy and thoroughness. • Looks for ways to improve and promote quality and monitors own work to ensure quality is met. • Must demonstrate exceptional communication skills by conveying necessary information accurately, listening effectively and asking questions where clarification is needed. • Must be able to work independently, prioritize work activities and use time efficiently. • Must be able to maintain confidentiality.

🏖️ Benefits

• Health insurance • 401(k) • Paid time off