QA Review Nurse

At PRI, we’re passionate about driving integrity and advancing quality across the healthcare system. As a trusted leader in the industry, we’re tackling some of healthcare’s biggest challenges—improving compliance, advancing health equity, and enhancing quality and clinical outcomes while helping organizations improve care delivery and create meaningful change. We believe that people are at the heart of healthcare, and focus on scalable, person-centered strategies that prioritize clinical excellence and evidence-based practices. Our work supports a broad network of stakeholders, including providers, patients, caregivers, payers, and regulators. We strive to enhance experiences, improve outcomes, and foster a healthier future for all.

Reporting to the Director, the Quality Assurance (QA) Review Nurse will provide professional assessment, planning, coordination, implementation, and reporting of complex clinical data. This role supports the medical review operations of Provider Resources, Inc. (PRI). The QA Review Nurse will perform comprehensive medical record reviews to make utilization, quality of care, and standards of care determinations based on evidence-based standards of care, applicable coverage policies, and utilization and practice guidelines.

Perform medical record reviews in accordance with all State, Federal, and/or commercially mandated regulations. Develop and maintain a detailed project schedule, including administrative tasks involved in the project. Proactively manage and coordinate activities to ensure timeliness of deliverables, exceeding contractual obligations. Analyze patient records and participate in interdisciplinary collaboration with PRI staff and recognized teaming partners/subcontractors. Document all review information into the appropriate Medical Review form, report, and/or system, and communicate results to the appropriate supervisor. Utilize electronic health information imaging and Internet/Intranet resources for applicable research. Make clinical judgments based on evidence-based standards of care, review criteria, and nursing practice guidelines when applicable.