Quality Control Registered Nurse

Clearance Level
None
Category
Healthcare Claims
Location
Raleigh, North Carolina

REQ#: RQ104905

Travel Required: None
Requisition Type: Regular

Key Job Responsibilities

  • Performs quality review/fact finding while maintaining confidentiality, participates in department meetings, identifies individual and team deficiencies.
  • Collect and analyze Prior Authorization, Claims and Adjustments, and Claims Consent data for correctness.
  • Accurately documents audit finding utilizing designated audit tools.
  • Identifies system and/or operational issues hindering the attainment of quality performance standards.
  • Work with department leadership to develop performance improvement programs including development and tracking of corrective action plans to address any identified issues.
  • Provides issue identification, problem analysis and strategies for resolution and/or implementation.
  • Communicate with nursing staff on quality findings and provide educational opportunities to review staff.
  • Participate in workgroups that address both clinical and non-clinical internal activities.
  • Serve as knowledge expert to Prior Authorization, Claims and Adjustments, and Claims Consent.
  • Monitor and prepare reports on compliance activities and other topics.

Qualifications

  • RN and 10+ years experience in Medicaid or public healthcare sector.

Skills

  • Knowledge of Prior Authorization, Claims and Adjustments, and Claims Consent.
  • Ability to identify problems such as underutilization or overutilization of services
  • Establish and maintain effective working relationships with all levels of staff, other business segments, and clients.
  • Self-directed with positive attitude.
  • Experience working with a virtual team with variable reporting relationships.
  • Skilled with Microsoft (Word, Excel, PowerPoint, Outlook, SharePoint, & Teams), Zoom, and other web based applications.  

This position requires being fully vaccinated against COVID-19 by January 18, 2022 or the start date, if after January 18. Individuals who work in or reside in Texas or Montana or work outside of the United States may be excluded from this requirement.

We are GDIT. The people supporting some of the most complex government, defense, and intelligence projects across the country. We deliver. Bringing the expertise needed to understand and advance critical missions. We transform. Shifting the ways clients invest in, integrate, and innovate technology solutions. We ensure today is safe and tomorrow is smarter. We are there. On the ground, beside our clients, in the lab, and everywhere in between. Offering the technology transformations, strategy, and mission services needed to get the job done.

GDIT is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status, or any other protected class.