BHS Network TX
Nurse Quality Analyst - Remote
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Job Description
- Req#: 87808281248
Employer Industry: Healthcare Services
Why consider this job opportunity:
- Salary up to $46.28 per hour
- Potential eligibility for a signing bonus for qualified new hires
- Comprehensive benefits package including medical, dental, vision, and life insurance
- Minimum of 12 days of paid time off per year, with accrual based on hours worked
- 401k plan with up to 6% employer match
- Opportunity to work in a supportive environment focused on improving healthcare services
What to Expect (Job Responsibilities):
- Perform retrospective medical necessity reviews to assess the appeal potential of clinical disputes and denials
- Utilize medical necessity criteria, such as InterQual®, to construct and document clinical cases for appeals
- Follow documented processes to support the clinical appellate process while adhering to productivity and quality goals
- Serve as a resource for non-clinical personnel and assist in process improvement initiatives
- Collaborate with the Law Department on medical necessity reviews and attend mediation hearings as required
What is Required (Qualifications):
- Must possess a valid Registered Nurse (RN) license
- Minimum of 3 years of recent acute care experience in a facility environment
- Critical thinking skills with the ability to make independent decisions regarding medical necessity
- Excellent written and verbal communication skills
- Knowledge of managed care contracts and reimbursement processes
How to Stand Out (Preferred Qualifications):
- Minimum of 2 years of experience in Utilization Review or Case Management
- Experience in medical-surgical or critical care settings
- Previous instruction on InterQual® products (Acute Adult, Pediatrics, Outpatient, and Behavioral Health) preferred
- Familiarity with managed care payer systems and processes
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