Quality Review Registered Nurse

Prince George's County, MD
Jan 29, 2018
May 01, 2018
IT, QA Engineer, Nurse
Full Time
The Medical Quality Review Nurse independently performs clinical assessment functions of the review program as outlined by procedures, by conducting an initial screening for the Expert Reviewer/Medical Director. This position is responsible for investigating, examining, collecting and reporting all quality assurance issues to all staff at the facility.

Essential Responsibilities

  • Performs comprehensive review of medical records to determine medical necessity, appropriateness of utilization level of care, and quality issues in accordance with pre-established criteria.
  • Refers all potential adverse decisions to the Expert Reviewer/Medical Director or peer review.
  • Identifies areas in criteria for potential modification and makes appropriate recommendations.
  • Responsible for case specific or plan specific reports which includes but is not limited to technology systems. Enters data in various databases.
  • Completes inquiry letters and final determination letters, case summaries, and provider performance reports within established time frames and minimal oversight.


Required Experience

  • Minimum 4-5 years of nursing experience
  • Minimum 2-3 years of QR or QA experience
  • Must have a valid, DC RN license
  • Certified Professional in Healthcare Quality, Certified Professional in Health Management, Utilization Review, HEDIS chart audits, Healthcare Fraud Examiner or Compliance, HUGE PLUS!!

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