Nurse Reviewer Job Description
Nurse reviewer
provides the clinical/administrative leadership for the coordination of the PACT Model and HBPC Program, including knowledge of regulations, VHA guidelines,, process improvement and compliance guidelines.
Nurse Reviewer Duties & Responsibilities
To write an effective nurse reviewer job description, begin by listing detailed duties, responsibilities and expectations. We have included nurse reviewer job description templates that you can modify and use.
Sample responsibilities for this position include:
Completion of Pre-Admission Screening assessments done in nursing facilities, hospitals, and community settings
Conducting formal reviews and authorizations of assessments completed by multiple stakeholders
Conducting quality assurance audits of various staff practices to ensure compliance with policies and procedures
Collecting, reviewing and analyzing data to ensure effective utilization of resources
Evaluating program effectiveness and delivery of services
Developing reports and reporting findings / recommendations to the Quality Assurance Manager, management staff, other related staff and quality assurance committees
Demonstrates accuracy and thoroughness, identifies process improvements
Managing important documents
Verifying documents
Inputting information accurately
Nurse Reviewer Qualifications
Qualifications for a job description may include education, certification, and experience.
Licensing or Certifications for Nurse Reviewer
List any licenses or certifications required by the position: ABQAURP, CPR, ACLS, CPHQ, BLS, CCM, CIC, AAPC
Education for Nurse Reviewer
Typically a job would require a certain level of education.
Employers hiring for the nurse reviewer job most commonly would prefer for their future employee to have a relevant degree such as Bachelor's and Associate Degree in Nursing, Nursing Program, Graduate, Education, Associates, School of Nursing, Science, Health, Nursing Education, Department of Education
Skills for Nurse Reviewer
Desired skills for nurse reviewer include:
Successful application of basic level of health care data analysis and clinical review
Applicable state regulations
Managed healthcare programs - HMO
POS are
PPO
Business process improvement techniques and strategies
Guidelines and coverage issues
Health regulations
Statistical terminology and use of statistics
MassHealth regulations
Desired experience for nurse reviewer includes:
Completing various other high priority administrator functions as requested
Assists in overseeing cases by ensuring case files contain all information necessary to do the review, if not, obtaining the documentation necessary to provide a fair and equitable review determination
Performs clinical reviews and data collection for, including database entry
Checks conflict of interest
Obtains case review clarification
Provides supporting reference documentation to the reviewer which may necessitate an online search for national guidelines, practice standards, peer reviewed published literature
Nurse Reviewer Examples
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Nurse Reviewer Job Description
Job Description Example
Our innovative and growing company is looking for a nurse reviewer. Thank you in advance for taking a look at the list of responsibilities and qualifications. We look forward to reviewing your resume.
Responsibilities for nurse reviewer
- Participates in issuing Review Results to client
- Communicates with appropriate parties regarding review (enrollee, authorized representative, health plan representative, state department of insurance, provider, facility
- In the absence of the IMR Service Line Manager, assumes responsibility for the daily operational functions of the IMR Department in respect to processing case reviews to assure that client & contractual deadline dates are met
- Review Receives requests for precertification of procedures via telephone, fax, or Web
- Reviews requests
- Collects additional data as necessary to evaluate request
- Applies appropriate criteria, such as Milliman Care Guidelines
- Assists with mailing and faxing of letters in the absence of an Intake Coordinator
- Assesses the necessity and reasonableness of the items supplied in a valid pre-claim review request through the use of medical policy
- Review medical records submitted by providers and make decisions using clinical judgment and CMS regulations
Qualifications for nurse reviewer
- Act as Subject Matter Expert for pre-claim review process and Home Health Reviews
- Implement changes made by CMS
- Coordinate pre-claim review process
- Responds to the most complex medical issues
- May participate in or on cross-functional teams, projects and initiatives, process improvement activities
- May serve as departmental liaison to other areas of the business
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Nurse Reviewer Job Description
Job Description Example
Our growing company is searching for experienced candidates for the position of nurse reviewer. Thank you in advance for taking a look at the list of responsibilities and qualifications. We look forward to reviewing your resume.
Responsibilities for nurse reviewer
- Comprehends complex policies and medical criteria as it pertains to member
- Maintain applicable abstraction and data entry completion, and accuracy standards
- Handle outgoing and incoming faxes
- Print, scan and copy materials
- Perform medical necessity reviews for Medicare appeals
- Review files to determine medical necessity of services at issue determine coverage under Medicare
- Research issues using federal law and Medicare regulations
- Coding duties as assigned
- Oasis review
- Complete other tasks as assigned to assist with operations of the Internal Department and other functional areas
Qualifications for nurse reviewer
- Minimum of 5 years of acute care clinical experience
- Communicates with health care professionals as a liaison regarding contract specifications and escalates issues as appropriate.- Participates on quality improvement teams.- Facilitates quality improvement plan development and implementation as requested, both internally and with External customers
- Completion of a certified ICD-9-CM and Oasis coding program within two (2) years of employment, required
- Minimum of five (5) years of progressive experience including a community health setting
- Regulatory background and HHRG reimbursement knowledge, required
- Proficiency in utilizing MS Word, Excel and Outlook
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Nurse Reviewer Job Description
Job Description Example
Our innovative and growing company is looking to fill the role of nurse reviewer. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for nurse reviewer
- Utilize standardized criteria to determine medical necessity
- Create written recommendations for approval
- Maintains productivity levels as defined by the Quality department
- Ensures that all data abstraction is performed accurately in accordance with criteria and definitions
- Utilizes working knowledge of hospital electronic medical record and other information systems required for abstraction of accurate data, Premier, Cerner
- Works collaboratively with peers to complete abstraction as assigned
- Maintains current knowledge of federal updates for Core Measure abstraction
- Supports system and campus teams as requested
- Ability to complete all pre‐training, on‐site training, and post‐training modules and pass the training post test
- NSQIP experience strongly preferred
Qualifications for nurse reviewer
- Minimum of three (3) years of active Minimal Data Set (MDS) responsibility or Medical Record Review/Auditing
- Knowledge of Prospective Payment System (PPS) and Medicaid reimbursement
- Knowledgeable in SNF/LTC reimbursement and billing regulation, including but not limited to RAI guidelines, Case Mix Index (CMI) and state nursing facility documentation guidelines
- Proficient in ICD-10 code
- Knowledgeableof audit and compliance procedures
- Effectively communicates with co-workers and government agencies
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Nurse Reviewer Job Description
Job Description Example
Our company is growing rapidly and is hiring for a nurse reviewer. If you are looking for an exciting place to work, please take a look at the list of qualifications below.
Responsibilities for nurse reviewer
- Meet or exceed all performance standards established for this position and department
- Assesses the necessity and reasonableness of the items supplied in a valid claim through the use of medical policy and other materials
- Performs in-depth facility claim review for appropriate billing, quality, contract compliance and medical necessity
- Applies accurately Medical Policies and guidelines
- Preps claim and medical records electronically for Medical Director review
- Researches contract language and updates tools as needed with the team
- Participates in team meetings, team building activities and team problem solving
- May be a lead for special projects/committees/guideline updates
- Writes and Formats appeal letter results
- Meet production timelines individually and turnaround times for regulatory requirements
Qualifications for nurse reviewer
- Highest level of professionalism with the ability to maintain confidentiality, and exhibits understanding and compliance with HIPAA standards
- Occasional travel, including occasional overnight stays
- Ability to work varied or flexible hours based on facility/home office needs
- Review and audit all portions of the medical record including but not limited to past medical and surgical history, medication lists, specialty and primary care notes, imaging, hospital records, labs and vital signs
- Review and audit all current and outstanding diagnoses for patients
- Provides debriefings with clinicians, using all required reports including newly suggested chart reviewed diagnoses
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Nurse Reviewer Job Description
Job Description Example
Our growing company is hiring for a nurse reviewer. Thank you in advance for taking a look at the list of responsibilities and qualifications. We look forward to reviewing your resume.
Responsibilities for nurse reviewer
- Conducts pre-certification, concurrent (if not associated with CM or DM triage), retrospective, out of network and appropriateness of treatment setting
- Reviews within scope of licensure by utilizing appropriate medical policies and clinical guidelines in compliance with department guidelines and consistent with the members eligibility, benefits and contract
- Audits and reviews Medicare/non-Medicare charts to ensure that proper HHRG standards are maintained in compliance with Federal and State regulations
- Applies ICD-9-CM coding rules and regulations to the HHRG Validation review process
- Instructs professional staff in ICD 9 changes, as needed
- Assists clinical staff and nursing supervisors in providing appropriate documentation in the Medical Record
- Reports to supervisor and visiting nurses those Medical Records that are deficient in diagnosis and clinical documentation
- Reviews Outcome Assessment Information Set (OASIS) and visit documentation for errors and inconsistencies related to clinical documentation, including wounds
- Discusses findings related to OASIS reviews and advises supervisors and DPS of needed corrections
- Processes medical appeals according to strict guidelines and timelines provided by the state
Qualifications for nurse reviewer
- Recommends ongoing chart review process to ensure continued high standards in coding and documentation
- Aid in the development and implementation of processes for ongoing coding and documentation education for providers
- Attends courses as needed to improve knowledge of coding and documentation
- Current RN license in Pennsylvania
- 5 years of General Clinical experience required, MediCare Advantage experience preferred
- Two years of clinical coding claims review and utilization experience with strong attention to detail and a high level of accuracy