Quality Review Nurse Quality Review NurseWho are we? Versant Health is one of the nation's leading administrators of managed vision care, serving millions of our clients' members nationwide. We are driven by our mission to help members enjoy the wonders of sight through healthy eyes and vision. As a Versant Health associate, you can enjoy a comprehensive Total Rewards package, which includes health and dental insurance, tuition reimbursement, 401(k) with company match, pet insurance, no-cost-to-you vision insurance for you and your qualified dependents. We are also invested in your success. There are many opportunities for advancement and development throughout all stages of your career with us. See how you can make a difference with the support of strong leadership and a team environment. See Everything, Be Anything™. What are we looking for? The Quality Review Nurse will work within the Utilization Management team to bring additional clinical expertise to the prior authorization and denial review processes. The Quality Review Nurse applies specific criteria and payer guidelines to ensure that all health care services provided are optimized for quality and timeliness of the care for all line of business (Medicare, Medicaid, Commercial). The Quality Review Nurse will be the clinical support person for the Utilization Management Team. The Quality Review Nurse will serve as a subject-matter-expert (SME) for member friendly language and denial letter review. This role requires a detail-oriented person who can manage multiple efforts to completion with minimal oversight. Where you will have an impact
- Serve as a clinical resource to the Utilization Management Team
- Serve as a SME for member friendly languagenotification letters
- Quality Clinical Review of all denial letters and makes edits to ensure letters meet all NCQA and regulatory requirements
- medical criteria and payer guidelines when reviewing clinical documentation for medical necessity
- Ensure services provided to eligible members are within benefit plan and appropriate contracted providers are being utilized
- Maintains a quality tracking log of all letters reviewed
- Quality Clinical Review of authorization requests
- Apply specific Identify and refer cases for second level review, when necessary
- Follow and apply all regulatory requirements for assigned markets
- Monitor reporting to track missing diagnosis codes and update prior authorization to reflect properly assigned diagnosis codes on a weekly basis
- Work closely with utilization management leadership to ensure the continual compliance of all QA/QI initiatives
- Contributesto a positive work culture by modeling excellence in both work ethic and team interactions
- Other duties as assigned
What's necessary to do the job?
- Graduate from an accredited nursing program.
- Requires a current unrestricted LPN or RN license for the state of residence or compact state licensure
- 3+ years of related experience in utilization management
- 3+ years of clinical experience in acute care
- Knowledge and experience in the insurance, health, or vision care industry preferred
- Proficiency in Microsoft Office suite
HIPAA & Security Requirements All Associates must comply with the Health Insurance Portability Accountability Act of 1996 (HIPAA) as it pertains to disclosures of protected health information (PHI) as described in the Notice of Privacy Practices and HIPAA Privacy Policies and Procedures. As a component of job roles and responsibilities, Associates may have access to covered information, cardholder data or other confidential customer information which must be protected at all times. As a result, Associates must explicitly adhere to all data security guidelines established within the Company's Privacy & Security Training Program. Versant Health will never request money from candidates who seek employment with us and will never ask for any payment as part of the recruitment process. Versant Health is a proud Equal Employment Opportunity and Affirmative Action employer dedicated to attracting, retaining, and developing a diverse and inclusive workforce. All qualified applicants will receive consideration for employment at Versant Health without regards to race, color, religion, sex (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity or expression, age, disability, national origin, marital or domestic/civil partnership status, genetic information, citizenship status, uniformed service member or veteran status, or any other characteristic protected by law. The wage range for applicants for this position is [$75,000.00 to $80,000.00]. All incentives and benefits are subject to the applicable plan terms.