Quality Assurance Nurse

PRIMARY PURPOSE: The Quality Assurance Specialist will provide comprehensive and quality oversight activities in line with the organization’s quality and medical case management standards. This position will report to the Director of Medical Education and Strategy within the Managed Care Organization. Focus for role with development and execution of the Quality Assurance Programs for both internal and external managed care clinical programs to align with AmTrust’s philosophy for holistic, injured employee centric approach to achieve best in class outcomes for claims. These responsibilities may include review of utilization review programs, pharmacy program clinical oversight, home health and all care coordination for claims in addition to identification and analysis of trends to provide recommendations for the overall program to further enhance and improve.

Responsibilities:

• Carry out quality assurance oversight activities defined in the AmTrust Medical Case Management and Quality Assurance Standards.
• Conduct regular and systematic review of Managed Care internal and external medical case management files with focus towards validation of comprehensive case assessments, evaluations and proactive strategies developed and executed to address medical and disability management, treatment and pharmacological plans to ensure evidence-based medicine is evaluated consistently.
• Conduct regular and systematic review of Managed Care programs both internal and external including but not limited to utilization review, pharmacy, home health services, diagnostic, physical medicine and independent medical evaluations.
• Reviews to also focus towards completion of activities and case management goals are in a timely manner, have appropriate follow ups, appointments are made within recommended frequency, ensure there are no gaps in service and medical care coordination.
• Analysis of Quality Assurance reporting metrics to identify strengths, trending and provide recommendations which can support and tie into educational training development needs for the overall programs.
• • Measure and identify staffing competency levels from quality assurance reviews.
• Track, monitor, and measure quarterly and annual performance of the programs.
• Present reports, findings, and recommendations for enhancements and/or changes based on analysis to the Managed Care Leadership and Workers’ Compensation leadership teams on both internal and external case management programs.
• Work with managed care leadership and nurses to calibrate quality standards across all offices.
• Review and conduct evaluation of external managed care clinical programs to ensure service level agreements, and performance measures are met and/or exceeded.
• Conduct billing and financial audits for external strategic partners to ensure compliance with contracted financial agreements.
• Act as liaison with external and internal strategic partners to manage overall quality measures of the case management program.
• Other duties may be assigned.

Qualifications:

• Active unrestricted RN license in a state or territory of the United States is required.
• Bachelor’s degree in nursing (BSN) from an accredited college or university or equivalent work experience or equivalent work experience preferred.
• Certification in case management, rehabilitation nursing or a related specialty is required (CCM, COHN, CRRN, etc.).
• Quality Assurance program designations such as Health Care Quality and Management certification (HCQM) highly preferred.
• Acquisition and maintenance of insurance license(s) may be required to comply with state requirements.

• Minimum five (5) years of related experience required to include two (2) years of direct clinical care, and two (2) years of case management and minimum of one (1) year in quality assurance role is required. Prior analytical experience with data and reporting outcomes in managed care setting is required. Understanding and prior experience with URAC accreditation and utilization review programs is required.
• Preferred previous clinical experience emergency room, critical care, home care or rehabilitation experience.
• Skills and Knowledge Requirements:
• Knowledge of workers’ compensation laws and regulations
• Knowledge of case management practice
• Knowledge of the nature and extent of injuries, periods of disability, and treatment needed
• Knowledge of URAC standards, ODG, Utilization review, state workers compensation guidelines
• Knowledge of pharmaceuticals to treat pain, pain management process, drug rehabilitation
• Knowledge of behavioral health
• Excellent oral and written communication, including presentation skills
• PC literate, including Microsoft Office products
• Leadership/management/motivational skills
• Analytic and interpretive skills
• Strong organizational skills
• Excellent interpersonal and negotiation skills
• Ability to work in a team environment
• Ability to meet or exceed Performance Competencies

What We Offer: