Clinical Quality Assurance Nurse Auditor (30490)

Are you a detail-oriented RN with a passion for clinical excellence and quality assurance? Join MES as a Clinical Quality Assurance Nurse Auditor, where you'll play a key role in ensuring the accuracy, integrity, and compliance of clinical documentation.

In this role, you'll evaluate clinical information submitted by healthcare providers and craft high-quality reports that meet client expectations and regulatory standards. You'll also serve as a resource for quality assurance inquiries and provide vital support to the QA department.

This position is 100% remote with a schedule of Monday through Friday: 9:00am-5:30pm EST.

Responsibilities May Include:

• Evaluate clinical information received, write and/or review various reports including, but not limited to, Medical Record Reviews, Medical Record Chronologies, Provider Bill Reviews, Coding Reviews, Hospital Bill Reviews, List of Missing Records, Medical Bill Apportionments, Mock Billing Invoice and Medical Summary Statements.
• Perform quality assurance review of peer review reports, correspondences, addendums or supplemental reviews.
• Ensure clear, concise, evidence-based rationales have been provided in support of all recommendations and/or determinations.
• Ensure that all client instructions and specifications have been followed and that all questions have been addressed.
• Ensure each review is supported by clinical citations and references when applicable and verify that all references cited are current and obtained from reputable medical journals and/or publications.
• Ensure the content, format, and professional appearance of the reports are of the highest quality and in compliance with company standards.
• Ensure the appropriate board specialty has reviewed the case in compliance with client specifications and/or state mandates and is documented accurately on the case report.
• Verify that the reviewer has attested to only the facts and that no evidence of reviewer conflict of interest exists.
• Ensure the provider credentials and signature are adhered to the final report.
• Identify any inconsistencies within the report and contacts the Reviewer to obtain clarification, modification or correction as needed.
• Contact the appropriate person to recover any missing documentation or verify charges.
• Assist in resolution of customer complaints and quality assurance issues as needed.
• Ensure all federal ERISA or state mandates are adhered to at all times.
• Provide insight and direction to management on consultant quality, availability and compliance with all company policies and procedures and client specifications.
• Promote effective and efficient utilization of company resources.
• Participate in various continuing education requirements and or training activities.
• Perform other duties as assigned.

Make a meaningful impact from wherever you are - apply today and help us raise the bar in clinical quality assurance.

Bachelor/Associate degree in nursing or related field; or minimum five years related experience; or equivalent combination of education and experience. Experience with medical terminology, medications, medical specialties and treatment protocols required. Experience in the insurance industry preferred.

• Must have strong knowledge of medical terminology, anatomy and physiology, medications and laboratory values.
•  Must be able to add, subtract, multiply, and divide in all units of measure, using whole numbers and decimals; Ability to compute rates and percentages.
• Must be a qualified typist with a minimum of 40 W.P.M
• Must be able to operate a general computer, fax, copier, scanner, and telephone.
• Must be knowledgeable of multiple software programs, including but not limited to Microsoft Word, Outlook, Excel, and the Internet.
• Must possess excellent skills in English usage, grammar, punctuation and style.
• Ability to follow instructions and respond to upper managements’ directions accurately.
• Demonstrates accuracy and thoroughness. Looks for ways to improve and promote quality and monitors own work to ensure quality is met.
• Must demonstrate exceptional communication skills by conveying necessary information accurately, listening effectively and asking questions where clarification is needed.
• Must be able to work independently, prioritize work activities and use time efficiently.
• Must be able to maintain confidentiality.

MES Solutions is a premier provider of independent medical examination and peer review services to the insurance, corporate, legal, and government sectors. Members of our credentialed medical panel conduct physical examinations or medical record reviews, delivering reports that assist clients in the resolution of automotive, disability, liability, and workers' compensation claims. MES has been providing services nationally since 1978 in accordance with the industry's highest standards of operating excellence and regulatory compliance.

MES offers a fast-paced team atmosphere with competitive benefits (medical, vision, dental), paid time off, and 401k.

Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, pregnancy, genetic information, disability, status as a protected veteran, or any other protected category under applicable federal, state, and local laws.