Nurse Reviewer - Reading, PA

Healthcare Quality Strategies, Inc. (HQSI) offers independent medical review services for private and government insurers, hospitals, third-party administrators, and employers. As a URAC-certified organization and a member of NAIRO, HQSI performs reviews across all major medical specialties while upholding the highest ethical and professional standards. HQSI efficiently and accurately conducts reviews in the following areas: • Medical necessity • Appropriateness of setting • Level of care • Quality of care • Experimental treatments/procedures • Coding • DRG assignment With over 25 years of experience in health quality improvement, HQSI collaborates with providers, communities, and government agencies, including the Centers for Medicare & Medicaid Services, to enhance the safety, efficiency, and effectiveness of healthcare.

PT (20-30 hours week) – Remote Work Environment Non-Exempt: $40.00 hour Supports Medical Review Services. The Nurse Reviewer plays a critical role in supporting the Medical Review Services department by performing comprehensive medical necessity reviews and policy reviews for Medicaid claims. This involves meticulous examination of claims and medical records to ensure compliance with established guidelines and regulations. The RN will work closely with the Team Lead, Physician Peer Reviewer and contract team. Reviews must be completed timely.

Conduct comprehensive medical record reviews to assess medical necessity and compliance with established standards of care and applicable policies Manage end-to-end case screening processes, ensuring all activities are completed within established deadlines Document evidence-based criteria applicable to specific contract requirements Record and report screening results, including relevant referral questions, into a centralized database Evaluate medical claims against industry standards, utilizing research of relevant ICD-10, CPT, and HCPCS codes to determine medical necessity Maintain expert knowledge of evolving multi-state Medicaid policies and vendor expectations Participate in ongoing training and consistently meet or exceed productivity and quality assurance standards