*** All candidates must reside in the Pacific Time Zone. You must also be a Registered Nurse (RN) with an active license and have ICU experience. ***
Why Join Us?
Are you a meticulous RN who loves diving into clinical data? Do you want to use your medical expertise outside of direct patient care to impact healthcare integrity?
As our Clinical Quality Assurance Nurse Auditor, you will be the final line of defense for medical accuracy and compliance. Your expertise ensures that clinical reports, medical record chronologies, and billing reviews are bulletproof, evidence-based, and of the highest professional standard. This is a high-impact role where your sharp clinical eye directly protects patients, providers, and healthcare standards.
What You Will Do (Your Impact)
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Champion Report Excellence: Review and refine critical medical reports, chronologies, and provider bills to ensure flawless clinical accuracy and professional presentation.
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Uphold Evidence-Based Medicine: Verify that every clinical determination is backed by robust, current citations from reputable medical journals.
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Act as a Strategic Partner: Collaborate directly with reviewing physicians to clarify complex case details and resolve inconsistencies.
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Guard Compliance & Integrity: Ensure full alignment with federal ERISA regulations, state mandates, and client specifications, while strictly verifying that no conflicts of interest exist.
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Solve Problems Proactively: Help resolve client quality questions, recover missing medical data, and provide management with strategic insights on consultant performance.
What You Bring to the Team
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Clinical Expertise: Active Registered Nurse (RN) license with strong clinical judgment.
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A Sharp Eye for Detail: Exceptional proofreading, auditing, and analytical skills.
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The Ability to Connect Dots: Deep understanding of medical coding, hospital billing, and record chronologies.
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Regulatory Knowledge: Familiarity with state and federal healthcare mandates (like ERISA) is a massive plus.
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Communication Skills: Ability to give constructive feedback to medical peers and providers with professionalism and clarity.
Organ donations
Organ Procurement
Intensive Care Unit (ICU)
MINIMUM REQUIRED QUALIFICATIONS
Education and/or Experience
Bachelor/Associate degree in nursing or related field; or minimum five years related experience; or equivalent combination of education and experience. Experience with medical terminology, medications, medical specialties and treatment protocols required. Experience in the insurance industry preferred.
Certificates, Licenses, Registrations
Evaluate clinical information received, write and/or review various reports including, but not limited to, Medical Record Reviews, Medical Record Chronologies, Provider Bill Reviews, Coding Reviews, Hospital Bill Reviews, List of Missing Records, Medical Bill Apportionments, Mock Billing Invoice and Medical Summary Statements.
Perform quality assurance review of peer review reports, correspondences, addendums or supplemental reviews.
Ensure clear, concise, evidence-based rationales have been provided in support of all recommendations and/or determinations.
Ensure that all client instructions and specifications have been followed and that all questions have been addressed.
Ensure each review is supported by clinical citations and references when applicable and verify that all references cited are current and obtained from reputable medical journals and/or publications.
Ensure the content, format, and professional appearance of the reports are of the highest quality and in compliance with company standards.
Ensure the appropriate board specialty has reviewed the case in compliance with client specifications and/or state mandates and is documented accurately on the case report.
Verify that the reviewer has attested to only the facts and that no evidence of reviewer conflict of interest exists.
Ensure the provider credentials and signature are adhered to the final report.
Identify any inconsistencies within the report and contacts the Reviewer to obtain clarification, modification or correction as needed.
Contact the appropriate person to recover any missing documentation or verify charges.
Assist in resolution of customer complaints and quality assurance issues as needed.
Ensure all federal ERISA or state mandates are adhered to at all times.
Provide insight and direction to management on consultant quality, availability and compliance with all company policies and procedures and client specifications.
Promote effective and efficient utilization of company resources.
Participate in various continuing education requirements and or training activities.
Perform other duties as assigned.
ExamWorks is an Equal Opportunity Employer and affords equal opportunity to all qualified applicants for all positions without regard to protected veteran status, qualified individuals with disabilities and all individuals without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age or any other status protected under local, state or federal laws.
Equal Opportunity Employer - Minorities/Females/Disabled/Veterans
