Quality Review Nurse (Remote) ID-6714

January 11, 2025

PURPOSE:

The role of the Quality Review Nurse (RN) is to evaluate clinical quality and procedures within the Clinical Appeals & Grievance Department Government Programs (Maryland Medicare and Medicaid). This includes auditing clinical appeals and grievance letters/documentation, reporting and analysis to ensure compliance with regulatory standards and assisting with department training. Collaborates with other business units: Utilization Management, Case Management, Claims, Quality Management and Compliance. The Nurse, Quality Review position develops procedures and reinforce quality standards to support critical-thinking skills and additional training as needed. We are looking for an experienced professional to work remotely from within the greater Baltimore metropolitan area. The incumbent will be expected to come into a CareFirst location periodically for meetings, training and/or other business-related activities.

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ESSENTIAL FUNCTIONS:

Reviews Clinical Appeals and Grievances documentation written by the clinical appeals nurse and non-clinical supporting team members within the Appeals and Grievance Department for Government Programs. Creates, updates and maintains a systematic audit tool to measure compliance with Appeals and Grievance standard operating procedures and Maryland Medicaid and Medicare, Qlarant, and NCQA standards. Utilizes the audit tool to identify areas of opportunities for quality improvement of clinical appeals and grievance process, documentation, and training that ensures compliance with departmental process and procedures, compliance and regulatory standards.
Trends results of clinical reviews. Creates presentations identifying strengths and areas of opportunity related to the appeals and grievance management team. Collaborates with the training team, department business analyst, and the clinical appeals and grievance management team to develop resources for appeals and grievance education as well as providing individual 1:1 support as needed. Establishes timeframe to re-evaluate implemented strategies and education.

QUALIFICATIONS:

Education Level: Bachelor's Degree in Nursing OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.

Licenses/Certifications:

Health Services\RN - Registered Nurse - State Licensure and/or Compact State Licensure Upon Hire Required.

Experience: 5 years Clinical nursing experience. 3 years quality auditing and improvement, training, mentoring, coaching, and providing feedback for improvement

Preferred Qualifications:

Master's degree in nursing
Clinical appeals and grievance experience with government programs, Utilization Management,
Managed Care experience, Experience with MCG, InterQual, NCD and LCDs.

Knowledge, Skills and Abilities (KSAs)

Exhibits interest in an understanding of health economics. Embraces the corporate mission to ensure access to affordable care and applies clinical knowledge and skills with the business operations framework.
Must be able to establish effective partnerships with other business units, schedule effective meetings, soliciting feedback, and working proactively.
Demonstrated excellent written and oral communication skills along with effective presentation skills. Able to provide verbal and written feedback for improvement. Includes the ability to formulate action plans for performance improvement. Must understand the appropriate mode of communication based on the subject matter.
Ability to identify quality trends and proactively develops action plans to improve quality metrics.
Ability to develop reporting method to track progress on improvement efforts.
Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.