Nurse Quality Analyst

Description: • Performs retrospective (post –discharge/ post-service) medical necessity reviews to determine appellate potential of clinical disputes/denials or those eligible for clinical review. • Demonstrates proficiency in use of medical necessity criteria sets, currently InterQual® or other key factors or systems as evidenced by Inter-rater reliability studies and other QA audits. Constructs and documents a succinct and fact based clinical case to support appeal utilizing appropriate module of InterQual® criteria (Acute, Procedures, etc). If clinical review does not meet IQ criteria, other pertinent clinical facts are utilized to support the appeal. Pertinent clinical facts include, but are not limited to, documentation preventing a safe transfer/discharge or documentation of medical necessary services denied for no authorization. • Demonstrates ability to critically think and follow documented processes for supporting the clinical appellate process. • Adheres to the department standards for productivity and quality goals. Ensuring accounts assigned are worked in a timely manner based on the payor guidelines. • Demonstrates proficiency in utilization of electronic tools including but not limited to ACE, nThrive, eCARE, Authorization log, InterQual®, VI, HPF, as well as competency in Microsoft Office. • Demonstrates basic patient accounting knowledge i.e. UB92/UB04 and EOB components, adjustments, credits, debits, balance due, patient liability, denials management, etc. • Additional responsibilities: • Serves as a resource to non-clinical personnel. • Provides CRC leadership with sound solutions related to process improvement • Assist in development of policy and procedures as business needs dictate. • Assists Law Department with any medical necessity reviews as capacity allows up to and including attending mediation hearings, other litigation forums, etc. Requirements: • Must possess a valid nursing license (Registered or Practical/Vocational) • Minimum of 5 years recent acute care experience with the last 2 years in a facility environment • Medical-surgical/critical care experience preferred • Minimum of 2 years UR/Case Management experience within the last 2 years • Managed care payor experience a plus either in Utilization Review, Case Management or Appeals • Patient Accounting experience a plus • Previous classroom led instruction on InterQual® products (Acute Adult, Peds, Outpatient and Behavioral Health) preferred Benefits: • Medical, dental, vision, disability, and life insurance • Paid time off (vacation & sick leave) – min of 12 days per year, accrue at a rate of approximately 1.84 hours per 40 hours worked. • 401k with up to 6% employer match • 10 paid holidays per year • Health savings accounts, healthcare & dependent flexible spending accounts • Employee Assistance program, Employee discount program • Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, AD&D, auto & home insurance. • For Colorado employees, Conifer offers paid leave in accordance with Colorado’s Healthy Families and Workplaces Act. Apply tot his job