Nurse Reviewer - Reading, PA

Current Employment Opportunities

About the Role

The Nurse Reviewer position supports Medical Review Services, focusing on comprehensive medical necessity reviews and policy assessments for Medicaid claims.

Responsibilities

• Conduct thorough medical record reviews to evaluate medical necessity and compliance with established standards
• Manage end-to-end case screening processes, ensuring timely completion within set deadlines
• Document evidence-based criteria and relevant referral questions into a centralized database
• Evaluate medical claims against industry standards using ICD-10, CPT, and HCPCS codes to determine medical necessity
• Maintain up-to-date knowledge of evolving Medicaid policies and vendor expectations
• Participate in ongoing training and meet productivity and quality assurance standards

Requirements

• Medical terminology, ICD-10, CPT and HCPCS codes
• Clinical criteria (InterQual and MCG)
• Utilization/Medical record review and chart abstraction
• Current standards of medical practice
• Compliance with HIPAA/HITECH laws and regulations
• At least three to five years of medical record review and/or abstraction experience (preferred)
• Experience with Medicare and Medicaid policy
• Proficiency with Microsoft Office (Word, Excel, Outlook)
• Proficiency with Adobe PDF files and features
• Ability to generate accurate, timely, and understandable correspondence
• Current experience applying clinical screening criteria (InterQual and MCG) within the last three years

Skills

• Professional interpersonal skills
• Solid analytical, assessment, and documentation skills
• Effective written and verbal communication
• Strong attention to detail
• Strong attention to deadlines
• Organizational skills including time management, priority setting, and process improvement
• Ability to work independently and as part of a team
• Adaptability to changing work situations and schedule adjustments

Qualifications

• BSN with active RN licensure in good standing

Benefits

This position offers Medical/Dental/Vision, FSA and HSA, group life/AD&D, voluntary life/AD&D, and a 401k plan. For immediate consideration, please apply via the HQSI Careers Page at: www.hqsi.org > Careers > Current Employment Opportunities. EOE: Minorities/Females/Disabled/Veterans

Physical Demands

Remote Work, Prolonged Sitting, Screen Exposure

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