TEXAS – Remote Clinical Quality Reviewer

Job Overview

  • Specialty License RN
  • State License(s) TX

HMS makes the healthcare system work better for everyone. We fight fraud, waste, and abuse so people have access to healthcare—now and in the future. Using innovative technology and powerful data analytics, we help government and commercial payers reduce costs, increase quality, and achieve regulatory compliance. We also help consumers take a more active role in their own health. Each year, we save our clients billions of dollars while helping people live healthier lives. At HMS, you will develop new skills and build your career in a dynamic industry while making a difference in the lives of others.

We are seeking a talented individual for a Clinical Quality Reviewer who is responsible for performing on-going assessments of the quality of work performed by Reviewers. This person is responsible for complex quality reviews to determine if decision by review staff matches medical records and approved review methodologies. This person is also responsible for working closely with the other clinical Supervisors and Managers to ensure that Clinical Reviewers are producing work that meets internal quality standards.

Essential Responsibilities:

  • Perform Quality Assurance checks on final review work during and after the orientation period. 
  • Coordinate with, and assist, Project Managers in performing ongoing IQC for all Nurse Reviewers and Project Specialists per department procedures or more often if problems are identified. 
  • Facilitate the Physician IQC process and communicates/coordinates frequently with the Chief Medical Officer regarding indentified physician learning needs. 
  • Offers quality improvement suggestions on project protocols and processes; facilitates quality improvement plan in conjunction with Manager.
  • Collaborate with Manager, Clinical Quality for identified quality issues.
  • Work with Review Supervisor/Sr. Nurse Reviewer/Service Line Manager to facilitate quality improvement plan development and implementation as needed for both internal and external customers. 
  • Serve as a subject matter expert for contributions to the business proposal process. 
  • Assist with project data analysis, reporting and feedback.

Non-Essential Responsibilities:

  • Performs other functions as assigned
Qualifications

:Knowledge, Skills and Abilities:

  • Demonstrated proficiency in medical record analysis and ICD-9-CM and CPT coding methodology or commercial utilization review guidelines.
  • Advanced knowledge of medical codes, coding conventions and rules.
  • Demonstrated experience in medical review, chart audits and quality improvement processes. 
  • Demonstrated experience with coding systems. 
  • Ability to demonstrate team processes and facilitate skills. 
  • Ability to apply healthcare data analysis to improve processes. 
  • Ability to work proficiently with Microsoft Word, Excel and Power Point. 
  • Ability to provide good customer service skills. 
  • Ability to medically review; chart audits, and quality improvement processes.
  • Ability to analyze information and use logic and process to address work-related issues and problems.
  • Ability to be careful and thorough about detail.
  • Ability to function under pressure and deadline oriented project demands as well as manage multiple initiatives. 
  • Ability to multi-task and prioritize. 
  • Ability to organize well. 
  • Ability to perform oral presentations.
  • Ability to work independently to meet objectives.
  • Working knowledge of HIPAA privacy and Security rules.

Work Conditions and Physical Demands:

  • Primarily sedentary work in a general office environment
  • Ability to communicate and exchange information
  • Ability to comprehend and interpret documents and data
  • Requires occasional standing, walking, lifting, and moving objects (up to 10 lbs.)
  • Requires manual dexterity to use computer, telephone and peripherals
  • May be required to work extended hours for special business needs
  • May be required to travel at least 10% of time based on business needs

Certifications: (Required/Desired)

  • Active unrestricted RN license or RHIA, RHIT, RN, CCS, CPC or other licensed/accredited health care professional specific to scope of contract required

Minimum Education:

  • High School Diploma or GED required
  • Associate’s or Bachelor’s degree preferred. 

Minimum Related Work Experience:

  • 3+ years clinical medical coding experience (1+ year clinical medical record auditing/validation experience required for coding only), preferably in a hospital setting 

OR

  • 5+ years clinical experience in appropriate setting

Nothing in this job description restricts management’s right to assign or reassign duties and responsibilities to this job at any time.