Description

1. Reports directly to: Project Manager – Fee for Service (FFS)

2. Other individuals or MetaStar staff with whom the person works on a regular basis: 
• External Quality Review Department staff
• Information Technology Department staff
• Hospitals
• Physician Reviewers
• Wisconsin Department of Health Services, Office of Inspector General (OIG) staff

3. Essential duties and responsibilities: 
To successfully perform this job, the individual must be able to perform each essential job function 
satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to 
perform the essential functions of this position.
• Conduct record review for Medicaid members including:
o Inpatient hospital records for fee-for-service Medicaid recipients to ensure compliance 
with state and federal requirements and generally acceptable standards of care to 
evaluate:
Medical necessity related to hospitalization
Quality/appropriateness of care
Accuracy of assigned diagnostic related groupings (DRG) assigned to record
o Medical/Health Home Record Review to evaluate compliance with program 
requirements
• Create clear and succinct written letters documenting review findings incorporating MetaStar’s 
corporate style guidelines.
• Develops and implements review activities independently and in collaboration with others in 
External Quality Review and staff from OIG. Review activities must align with state and federal 
requirements.
• Collaborates with team members to improve the existing systems/processes/standard operating 
procedures as well as develop new ones as identified.
• Participate in inter-rater reliability testing in order to achieve standards of accuracy and 
consistency in applying review standards for each review type.
• Review the work of others and collaborate with team members through ongoing feedback to 
ensure that work meets internal and external quality standards.
• All other duties as assigned

Requirements

QUALIFICATIONS, REQUIREMENTS, ETC. 
The requirements listed below are representative of the knowledge, skills, and/or abilities required to 
successfully perform this job at the minimum level. 
• Bachelor’s degree in nursing. Licensed Registered Nurse in good standing in the State of 
Wisconsin.
• Minimum of three years’ experience working at an inpatient hospital setting.
• Knowledge of ICD-10-CM coding.
• Knowledge of the conditions and current standards of practices within the following areas: 
mental health, substance abuse, obstetrics, or medical/surgical.
• Proficiency in Microsoft Office applications.
• Ability to work well independently and collaborate within a team structure.
• Ability to evaluate and apply review standards consistently. Ability to use standard operating 
procedures and department resources with critical thinking and judgement to conduct accurate 
and reliable reviews.
• Self-motivated, with a strong desire to learn and apply existing and new skills.
• Excellent oral and written communication skills, and the ability to interact positively with others.
Additional requirements are listed as preferred.
• Knowledge of continuous quality improvement, process improvement, and plan-do-study-act 
principles.
• Experience in performance measurement, quality assessment, and quality improvement 
projects or initiatives.

ORGANIZATIONAL CORE COMPETENCIES: 
• Contributes to MetaStar’s Mission, Vision, Values
• Uses Quality Improvement Concepts in Daily Practice
• Provides Excellent Customer Service
• Shows Initiative

PHYSICAL EFFORT AND WORKING CONDITIONS
The requirements and conditions described below are representative of the general environment the 
individual is exposed to on a day-to-day basis while performing this job.
Manual Dexterity: Ability to operate computer and telephone
Physical Effort: Ability to sit or stand for five-to-eight hours per day (depending on scheduled 
FTE); occasionally lifting up to 15 pounds.
Equipment Used: Computer and telephone
Working Conditions: Traditional office environment; required to work on a computer five-to-eight 
hours per day (depending on scheduled FTE)

MetaStar is proud to be an equal opportunity employer. We do not discriminate based upon race, religion, color, 
national origin, sexual orientation, gender identity, gender expression, age, status as a protected veteran, status 
as an individual with a disability, or other characteristics. We celebrate diversity and are committed to creating 
an inclusive environment for all employees