Review Nurse - PART-TIME

Summary

The Review Nurse performs clinical medical record review and abstraction to support healthcare quality, compliance, and project requirements. The role applies established review criteria consistently, documents findings clearly and objectively, and works independently to complete accurate reviews within project deadlines.

This position reviews medical and case management records across varied healthcare settings and may support multiple competing or overlapping projects. The Review Nurse uses sound clinical judgment, relevant evidence-based guidelines, and applicable coding or measure specifications while maintaining strong organization, technical proficiency, and attention to detail.

Essential Competencies, Duties and Responsibilities

Clinical Review and Abstraction

• Review and abstract medical and case management records in accordance with project requirements, established criteria, and applicable specifications
• Apply review criteria consistently and accurately across assigned records and projects
• Document review findings clearly, objectively, and completely
• Use clinical nursing experience to assess documentation related to the treatment and management of physical health conditions
• Support medical record review, clinical auditing, or similar healthcare review activities                                                       

Quality, Accuracy, and Compliance

• Follow approved review protocols, evidence-based clinical guidelines, and project instructions
• Identify documentation discrepancies or questions and escalate them through the appropriate project process
• Maintain accuracy, consistency, confidentiality, and data integrity when handling medical records and review results
• Meet established quality expectations, productivity requirements, priorities, and deadlines

Systems, Organization, and Collaboration

• Learn and use assigned systems, databases, and review tools effectively
• Work independently with minimal supervision while seeking guidance when requirements are unclear
• Organize and manage multiple priorities, deadlines, and competing or overlapping project needs
• Balance record review responsibilities with operational or project coordination activities as assigned
• Communicate review status, questions, and findings clearly with project leadership and team members

Additional Tasks

• Participate in training and quality review activities to support consistent application of review criteria
• Maintain required professional licensure and remain current with relevant clinical and healthcare review practices
• Perform other related duties and special projects in support of business and operational needs
• Demonstrate initiative, dependability, sound judgment, and appropriate follow-through in completing assigned work

Education and/or Experience

• Active, unrestricted Registered Nurse (RN) license
• Bachelor of Science in Nursing (BSN) or higher
• Minimum of 3 years of clinical nursing experience in a medical, surgical, acute care, ambulatory care, specialty care, long-term care, or other healthcare treatment setting involving the assessment, treatment, and management of physical health conditions
• Minimum of 2 years of experience in medical record review, clinical auditing, or similar healthcare review activities

Preferred Qualifications

• Certified Case Manager (CCM), Certified Professional in Healthcare Quality (CPHQ), or other relevant healthcare quality certification
• Experience with Medicaid, Medicare, managed care organizations (MCOs), External Quality Review Organization (EQRO) activities, Independent Review Organizations (IROs), or healthcare accreditation programs
• Experience conducting reviews using evidence-based clinical guidelines, including InterQual, MCG Care Guidelines, The ASAM Criteria, or similar resources
• Experience validating ICD-10-CM, CPT, and HCPCS codes against medical record documentation
• Experience with hybrid measure abstraction and medical record review, including NCQA HEDIS, NCQA LTSS, and CMS Adult, Child, and LTSS Core Set measures

Other Qualifications

• Technical aptitude and comfort learning new systems, databases, and review tools
• Strong organizational skills and the ability to manage multiple priorities and deadlines
• Ability to work independently with minimal supervision
• Ability to communicate and document findings clearly, accurately, and objectively
• Experience balancing review responsibilities with operational or project coordination activities