Are you passionate about improving the quality of healthcare?
Are you ready to leverage your talents to make healthcare better for everyone?
Do you want the opportunity to give back to your community?
Do you want to have fun at work?
Then join the growing team at Health Services Advisory Group (HSAG) that is transforming the delivery of healthcare in the United States!
Summary
The Review Nurse performs clinical medical record review and abstraction to support healthcare quality, compliance, and project requirements. The role applies established review criteria consistently, documents findings clearly and objectively, and works independently to complete accurate reviews within project deadlines.
This position reviews medical and case management records across varied healthcare settings and may support multiple competing or overlapping projects. The Review Nurse uses sound clinical judgment, relevant evidence-based guidelines, and applicable coding or measure specifications while maintaining strong organization, technical proficiency, and attention to detail.
Essential Competencies, Duties and Responsibilities
Clinical Review and Abstraction
- Review and abstract medical and case management records in accordance with project requirements, established criteria, and applicable specifications
- Apply review criteria consistently and accurately across assigned records and projects
- Document review findings clearly, objectively, and completely
- Use clinical nursing experience to assess documentation related to the treatment and management of physical health conditions
- Support medical record review, clinical auditing, or similar healthcare review activities
Quality, Accuracy, and Compliance
- Follow approved review protocols, evidence-based clinical guidelines, and project instructions
- Identify documentation discrepancies or questions and escalate them through the appropriate project process
- Maintain accuracy, consistency, confidentiality, and data integrity when handling medical records and review results
- Meet established quality expectations, productivity requirements, priorities, and deadlines
Systems, Organization, and Collaboration
- Learn and use assigned systems, databases, and review tools effectively
- Work independently with minimal supervision while seeking guidance when requirements are unclear
- Organize and manage multiple priorities, deadlines, and competing or overlapping project needs
- Balance record review responsibilities with operational or project coordination activities as assigned
- Communicate review status, questions, and findings clearly with project leadership and team members
Additional Tasks
- Participate in training and quality review activities to support consistent application of review criteria
- Maintain required professional licensure and remain current with relevant clinical and healthcare review practices
- Perform other related duties and special projects in support of business and operational needs
- Demonstrate initiative, dependability, sound judgment, and appropriate follow-through in completing assigned work
Education and/or Experience
- Active, unrestricted Registered Nurse (RN) license
- Bachelor of Science in Nursing (BSN) or higher
- Minimum of 3 years of clinical nursing experience in a medical, surgical, acute care, ambulatory care, specialty care, long-term care, or other healthcare treatment setting involving the assessment, treatment, and management of physical health conditions
- Minimum of 2 years of experience in medical record review, clinical auditing, or similar healthcare review activities
Preferred Qualifications
- Certified Case Manager (CCM), Certified Professional in Healthcare Quality (CPHQ), or other relevant healthcare quality certification
- Experience with Medicaid, Medicare, managed care organizations (MCOs), External Quality Review Organization (EQRO) activities, Independent Review Organizations (IROs), or healthcare accreditation programs
- Experience conducting reviews using evidence-based clinical guidelines, including InterQual, MCG Care Guidelines, The ASAM Criteria, or similar resources
- Experience validating ICD-10-CM, CPT, and HCPCS codes against medical record documentation
- Experience with hybrid measure abstraction and medical record review, including NCQA HEDIS, NCQA LTSS, and CMS Adult, Child, and LTSS Core Set measures
Other Qualifications
- Technical aptitude and comfort learning new systems, databases, and review tools
- Strong organizational skills and the ability to manage multiple priorities and deadlines
- Ability to work independently with minimal supervision
- Ability to communicate and document findings clearly, accurately, and objectively
- Experience balancing review responsibilities with operational or project coordination activities
Work Environment
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Disclaimer
This is not necessarily an exhaustive list of all responsibilities, skills, duties, requirements, efforts or working conditions associated with the position. While this is intended to be an accurate reflection of the current position, management reserves the right to revise the position or to require that other or different tasks be performed when circumstances change (e.g., emergencies, changes in personnel, work load, rush jobs requiring non-regular work hours, or technological developments).
HSAG is an EEO Employer of Veterans protected under Section 4212.
If you have special needs and require assistance completing our employment application process, please feel free to contact us.
EOE M/F/Veteran/Disability