Reviewer Jobs in Scottsdale, AZ

Job Summary

Ensures compliance with contract requirements for clinical quality management (CQM) to ensure quality care for Veterans. Identifies and evaluates potential quality issues and prepares summaries for further review and analysis. Supports activities of peer review and quality and safety committees. Reviews discharge summaries and consultation reports for compliance with clinical quality and contract requirements.

Education & Experience

Required :

o Registered Nurse or Licensed Clinical Social Worker, with current unrestricted license in appropriate state or territory of the United States o 3 years clinical experience (medical / surgical or behavioral health)

Preferred :

o Bachelor's in Nursing or Certified Professional in Healthcare Quality (CPHQ) o 1 or more years team lead or supervisory experience o 1 year experience in Quality Management o 1 year experience with data analysis and reporting o Experience with InterQual or similar criteria sets o General knowledge of Medicare, Veterans Administration, or other government health care programs

Key Responsibilities

o Identifies Potential Quality Issues (PQIs) by performing a timely review of medical documentation. This includes researching, investigating, analyzing, and preparing case summaries with appropriate recommendations for further actions.

o Develops peer review cases and other quality improvement activities for monitoring deviations from accepted standards of care and suggesting corrective action plans.

o Reviews Practice Pattern Analyses to assist with identifying physician practice patterns for confirmed severity cases.

o Collaborates with VA for data collection, reporting, and analysis of quality issues and contract compliance.

o Participates on safety and quality committees and peer review committees.

o Reviews Potential Quality Issues with Chief Medical Officer when appropriate.

o Provides support for the VA Clinical Quality committee meetings through case summary and report preparation.

o Provides supervisory / team lead support for Complex Authorization Specialists.

o Performs other duties as assigned.

o Regular and reliable attendance is required.

Competencies

Commitment to Task : Ability to conform to established policies and procedures; exhibit high motivation.

Computer Literacy : Ability to function in a multi-system Microsoft environment using Word, Outlook, TriWest Intranet, the Internet, and department software applications.

Independent Thinking / Self-Initiative : Critical thinkers with ability to focus on things which matter most to achieving outcomes; Commitment to task to produce outcomes without direction and to find necessary resources.

Leadership : Provide clear direction and effective coaching.

Organizational Skills : Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; Detail-oriented.

Problem Solving / Analysis : Ability to solve problems through systematic analysis of processes with sound judgment; Has a realistic understanding of relevant issues.

Technical Skills : General knowledge of Medicare, Veterans Administration, or other government health care programs; knowledge in the application of clinical criteria : InterQual, Milliman, PAS-LOS, ICD-9-CM, DSM, CPT-4, and HCPCs; Proficient with Microsoft Word and Excel

Working Conditions

Working Conditions :

o Works within a standard office environment, with minimal travel

o Ability to lift 20 pounds

o Security clearance as required by contract