Senior Quality Clinical Reviewer -RN

Albuquerque NM 87113

Job Description

Seeking a Bachelor's level RN and this position is onsite in the Albuquerque, NM office.

Applies clinical expertise in conducting standardized independent reviews of case management and provider documentation and treatment records. Conducts reviews of Quality of Care and Critical/Adverse Incidents following policies to identify patient safety risks and coordinates follow-up actions. Prepares reports for quality purposes based on findings and monitors follow-up actions and recommendations for improvement. Trends and analyzes findings for internal and external reporting. Interfaces with providers and customers.

-  Reviews charts and analyzes clinical record documentation against state, federal and accreditation standards and contract requirements using standard tools and reporting mechanisms.

-  Reviews Quality of Care and Critical/Adverse incidents to assess risk and patient safety issues based on policy and procedural guidelines. 

-  Conducts ongoing activities which monitor established quality of care standards in the provider network and for care managers.

-  Collects, analyzes and prepares clinical record information for projects related to assessing the efficiency, effectiveness and quality of the delivery of managed care services.  Prepares monthly performance reports with assistance from Reporting and Analytics unit.  Presents findings at management,  provider, customer  and quality meetings.

-  Assists in the planning and implementation of activities to improve delivery of services and quality of care including the development and coordination of in-service education programs for providers and care managers.

-  Responsible for auditing as well as validating internal audit results and/or corrective action plans.

General Job Information

Title

Senior Quality Clinical Reviewer -RN

Grade

24

Job Family

Quality Group

Country

United States of America

FLSA Status

United States of America (Exempt)

Recruiting Start Date

10/18/2019

Date Requisition Created

10/17/2019

Work Experience

Clinical, Quality

Education

Bachelors: Nursing (Required), Masters: Behavioral Health (Required)

License and Certifications - Required

LCSW - Licensed Clinical Social Worker - Care Mgmt, LMHC - Licensed Mental Health Counselor - Care Mgmt, LPC - Licensed Professional Counselor - Care Mgmt, MFT - Marriage and Family Therapist - Care Mgmt, RN - Registered Nurse, State and/or Compact State Licensure - Care Mgmt

License and Certifications - Preferred

Other Job Requirements

Responsibilities

-Bachelors level clinician (RN) NM State license required.

-Experience working with total quality improvement with a healthcare background in treatment modalities, psychopharmacology, federal/state regulatory guidelines, performance measurement.

-Ability to work independently with minimal supervision.

-Project management skills and demonstrated experience.

-Managed health care experience preferred.

-Clinician with direct care experience and file review auditing preferred.

-NCQA and URAC accreditation standards and processes experience preferred.

Licensed RN with 7 years healthcare quality improvement experience.

Magellan Health Services is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled. Every employee must understand, comply and attest to the security responsibilities and security controls unique to their position.

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