Quality Analyst (Remote, LPN/RN Required)

The Utilization Management Nurse Reviewer plays a crucial role in healthcare systems by ensuring that medical services are used efficiently and appropriately. They review medical records, treatment plans, and patient information to determine the necessity and appropriateness of medical procedures, tests, and treatments.

Location: Remote (US)

Salary: $45,000 - $70,000 USD

Responsibilities

• Conduct assessments of medical services to validate their appropriateness using established criteria and guidelines, ensuring the medical necessity of treatments (e.g., CMS, Milliman Care Guidelines, InterQual, or health plan specific guidelines/criteria).
• Examine and evaluate patient records to verify the quality of patient care and the necessity of provided services.
• Offer clinical expertise and serve as a clinical reference for non-clinical staff members.
• Input and manage essential clinical details within various medical management platforms.
• Keep up-to-date with regulatory prerequisites (such as URAC) and state standards for utilization review.
• Apply clinical reasoning to determine the suitable evidence-based guidelines.
• Foster efficient and high-quality patient care by effectively communicating with management teams, physicians, and the Medical Director.

Requirements

• Proficient in both written and spoken communication.
• Capable of maintaining professional communication with physicians and clients.
• Skilled at handling multiple tasks and adjusting swiftly in a dynamic office setting.
• Possesses a keen organizational sense and pays close attention to details.
• Adept at resolving intricate and multifaceted problems.
• Experienced with Microsoft tools such as Word, Excel, PowerPoint, and Outlook.
• Background in medical or clinical practice through education, training, or professional engagement.
• Holds an unrestricted LVN/RN license from an accredited vocational nursing program (for LVNs) or a nursing degree from an accredited college (for RNs).

Benefits

• Join our team at Dane Street and enjoy a comprehensive benefits package designed to support your well-being and peace of mind. We offer a range of benefits including medical, dental, and vision coverage for you and your family. Additionally, we offer voluntary life insurance options for you, your spouse, and your children. We also offer other voluntary benefits which include hospital indemnity, critical illness, accident indemnity, and pet insurance plans. Employees receive basic life insurance, short-term disability, and long-term disability coverage at no cost. Our generous paid time off policy ensures you have time to relax and recharge, while our 401k plan with a company match helps you plan for your future. Apple equipment and a media stipend are provided for remote workspace.

Additional Information

• The role requires working from home with the need to supply and support own internet services, maintaining an uninterrupted internet connection.
• The position offers a salary range of $45,000 - $70,000 USD, with compensation depending on experience, education, and skills.
• The role involves physical demands such as sitting for long periods and computer work.
• Additional duties include providing oversight to team members, improving processes, and acting as a liaison for quality issues.