Nurse Reviewer - Tampa, FL

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 of all activities
• Document evidence-based criteria applicable to specific contract requirements
• Record and report screening results, including 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
• 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 experience in medical record review and/or abstraction (preferred)
• Experience with medical record review, audits for federal or state contracts
• Knowledge and experience of Medicare and Medicaid policies
• Proficiency with Microsoft Office (Word, Excel, Outlook)
• Proficiency with Adobe PDF files and features
• Ability to generate accurate, timely, and understandable correspondence
• Current experience (within the last three years) in applying clinical screening criteria (InterQual and MCG)

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 effective time management, priority setting, and process improvement
• Ability to work independently and as part of a team
• Adaptability to changing work situations and flexible scheduling

Qualifications

• BSN with active RN licensure in good standing

Benefits

This position offers:

• Medical/Dental/Vision coverage
• FSA and HSA options
• Group life/AD&D insurance
• Voluntary life/AD&D insurance
• 401(k) plan

Pay

PT (20-30 hours per week) – Remote Work Environment

Non-Exempt: $40.00 per hour

Schedule

Remote Work

Prolonged Sitting

Screen Exposure

Apply for this Position

For immediate consideration, please apply via the HQSI Careers Page at: www.hqsi.org > Careers > Current Employment Opportunities

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