Clinical Quality Assurance Nurse Auditor

This is a fully remote position, open to applicants in Massachusetts.

📋 Description

• Assess clinical data received from healthcare providers

• Draft and/or evaluate Medical Record Reviews, Medical Record Chronologies, Provider Bill Reviews, Coding Reviews, Hospital Bill Reviews, lists of missing records, medical bill apportionments, mock billing invoices, and medical summary statements

• Conduct quality assurance assessments of peer review reports, correspondence, addendums, and supplemental reviews

• Ensure that clear, concise, evidence-based justifications underpin recommendations and decisions

• Confirm adherence to client instructions, specifications, contractual agreements, regulatory standards, and both federal and state mandates

• Support reviews with up-to-date clinical citations and credible medical references

• Guarantee that report content, format, and professional appearance conform to company standards

• Validate appropriate board specialty review and ensure accurate case-report documentation

• Confirm reviewer attestations, provider credentials, and signatures

• Detect report discrepancies and reach out to reviewers for clarification, modification, or correction

• Recover missing documentation or verify charges

• Assist in managing customer complaints and quality assurance concerns

• Offer management insights on consultant quality, availability, and compliance

• Encourage efficient use of company resources

• Engage in continuing education and training initiatives

• Execute other assigned responsibilities

⛳️ Requirements

• Bachelor’s/Associate degree in nursing or a related field; or a minimum of five years of relevant experience; or an equivalent combination of education and experience

• Valid RN/LPN license

• Must possess and maintain an unencumbered Registered Nursing license

• Proficient in medical terminology, medications, medical specialties, and treatment protocols

• Experience in the insurance sector preferred

• Strong understanding of medical terminology, anatomy and physiology, treatment protocols, medications, and laboratory values

• Competent typist with a minimum of 40 W.P.M.

• Proficient in using general office equipment such as computers, fax machines, copiers, scanners, and telephones

• Familiarity with Microsoft Word, Outlook, Excel, and the Internet

• Exceptional skills in English usage, grammar, punctuation, and style

• Ability to follow instructions and accurately respond to directives from upper management

• Capacity to work independently, prioritize tasks, and manage time effectively

• Ability to maintain confidentiality

• Capability to concentrate and remain focused despite frequent interruptions

• Ability to perform well under pressure or in stressful situations

• Proficiency in managing change, delays, or unexpected circumstances appropriately

• Reliability and compliance with the company attendance policy

• Professional and tidy appearance consistent with company standards

🏝️ Benefits

• Medical insurance

• Vision insurance

• Dental insurance

• Paid time off

• 401k

• Fast-paced team environment