Nurse Reviewer - Williamsport, 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 of all activities
• Document evidence-based criteria and report screening results using a centralized database
• Evaluate medical claims against industry standards, utilizing relevant ICD-10, CPT, and HCPCS codes
• Evaluate evolving multi-state 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
• Comply 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, and Outlook)
• Proficiency with Adobe PDF files and features
• Generate accurate, timely, and understandable correspondence
• Current experience (within the last 3 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 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.

Pay

PT (20-30 hours per week) – Remote Work Environment, Non-Exempt: $40.00 per hour

Schedule

Remote Work

Physical Demands

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

Go back to the job list