Review Associate I Job Opening at Quality Health Strategies in Easton, MD

Delmarva Foundation is a highly successful and rapidly growing, not-for-profit Company with a passion for excellence and over 35 years of experience in health care quality improvement. We offer an attractive compensation package with the opportunity for professional growth. We have an opening for a PRN (as needed) experienced Long Term Care Review Associate in our Easton, MD office.

The Review Associate is a Registered Nurse who independently performs clinical assessment functions of the review as outlined by Delmarva procedures, by conducting an initial screening for the Expert Reviewer/Medical Director. This review may be performed prior to admission, concurrently, or retrospectively, depending on contract requirements. May provide support to the management staff by assisting with writing policy and/or articles.

*Performs comprehensive review of medical records to determine medical necessity, appropriateness of utilization and/or coding and quality issues in accordance with pre-established criteria

*Refers all potential adverse decisions to the Expert Reviewer/Medical Director or peer review

*Identifies areas in criteria for potential modification and makes appropriate recommendations

*Responsible for case specific or plan specific reports which includes but is not limited to technology systems. Enters data in various databases

*Provides technical assistance to internal and external personnel

*Completes inquiry letters and final determination letters, case summaries, and provider performance reports within established timeframes and minimal oversight

*Completes the notification process, when required, including inquiry letters and final determination letters

*Completes coding validation on applicable cases, after appropriate training

*Participates in and/or lead internal and external meetings, as required, for feedback purposes. May also develop and participate in external presentations

*Has the responsibility and authority to perform their job and provide customer satisfaction.

Affirming equal opportunity in principle and practice, QHS is an equal opportunity employer, committed to developing a diverse workforce.

Please complete an online application including salary requirements at our careers website at:

*Must be a Registered Nurse (RN) with at 3 three years of clinical nursing experience and 1 year of review experience

*A Bachelor's Degree, preferably in health related field and at least two years of utilization review/quality assurance review experience OR certification in an applicable program such as CPHQ, ASC, CPHQ, Managed Care or Case Management, Project Management, Fraud Examiner, Compliance, AND 3 to 5 years related experience and/or training

*Must have the ability to work independently with minimal supervision.

*Must be able to communicate effectively with all members of the team to which he/she is assigned. Must have the ability to grasp and adapt to changes in procedure and process.

* Must have the ability to effectively resolve complex issues.

* May require some travel.