In this weekly feature, the editors of SpringBoard highlight one career in the health care professions–including a basic description, educational requirements, core competencies/key skills needed, and related web sites and professional organizations where you can find more information!

Basic Description

A compliance specialist nurse’s primary responsibility is to review medical record claims for a health care organization to assess accuracy of services and quality of care provided, and to assess whether these services have met practice and ethical standard requirements. He or she provides the review team with her clinical expertise in investigating a case.

Educational Requirements

Registered nurse preparation, Bachelor of Science in Nursing, and at least 3 years of clinical experience, preferably in home care, are desired in most job positions.

Core Competencies/Skills Needed

  • Experience in utilization review, risk management, and quality management
  • Strong background in clinical compliance, medical record review, and documentation
  • Knowledge of CPT and ICD-9 codes
  • Understanding of Medicare and Medicaid regulations
  • Must be ethical, objective, detail oriented, and able to work in a high-stress environment
  • Strong computer skills and knowledge and data management skills
  • Excellent communication, organizational, and interpersonal skills

Related Web Site and Professional Organization

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