RN - Clinical Quality Reviewer - Spectrum Healthcare Resources
Denver, CO
About the Job
Job Description
Spectrum Healthcare Resources has a potential need for Registered Nurse Clinical Quality Reviewer. These will be completely remote positions, working entirely from the Nurse’s home. The Nurse will be develop, implement and review health care plans for the dependents of our Nation’s Active Duty and eligible retirees. The Nurse will be working Monday through Friday, 8 hours per day.
Requirements
- Bachelors Nursing Degree
- At least one active state nurse license, preferably compact state licensure
- At least 3 years’ clinic experience (medical/surgical or behavioral health)
- Preffered:
- Bachelor's in Nursing or Bachelor’s degree in a health care field or Certified Professional in Healthcare Quality (CPHQ)
- 1 year experience in Clinical Quality Management
- 1 year experience with data analysis and reporting
- Experience with InterQual criteria or similar criteria sets
- General knowledge of Medicare, TRICARE, or other government healthcare programs
- Key Responsibilits:
- Identifies Potential Quality Issues (PQIs) by performing a timely review of the medical records. This includes researching, investigating, analyzing, and preparing case summaries with appropriate recommendations for further actions.
- Develops peer review cases and other quality improvement activities for monitoring deviations from accepted standards of care and suggesting corrective action plans.
- Responds to AHRQ concerns and documents a rationale for cases when TriWest's position does not concur with the AHRQ position.
- Requests Practice Pattern Analyses (trend) to assist with identifying physician practice patterns for confirmed severity cases.
- Identifies and refers cases for focused reviews to Clinical Quality Management Leadership.
- Performs focused study data collection, reporting, analysis, and makes recommendations for improvement.
- Refers cases for review as appropriate to Program Integrity, Case Management, Care Coordination, Population Health Improvement, Disease Management, Congressional Relations & Customer Grievances and other TriWest departments.
- Participates on quality committees.
- Reviews Potential Quality Issues with Medical Directors when appropriate.
- Highly organized, self-directed worker able to function in a high-volume environment without distractions.
- Strong verbal and written communication skills.
- Proficient level of experience with Microsoft Office applications and strong technical aptitude.
- Must have access to secure, high speed internet.
Company Overview:
Spectrum Healthcare Resources (SHR) was established in 1988 to deliver systems and processes designed to meet the unique needs of Military and VA Health Systems. SHR is a leading organization that provides physician and clinical staffing and management services to United States Military Treatment Facilities, VA clinics and other Federal Agencies through various contracting vehicles. A Joint Commission Health Care Staffing Services firm, SHR is the military staffing division of TeamHealth, a Nationwide organization that serves 850 civilian and military hospitals with a team of 9,600 affiliated health care professionals.
Spectrum Healthcare Resources is an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status, or any other characteristic protected by law.
EOE/AA/Disability/Vet
