Clinical Quality Assurance Coordinator

This is a fully remote position, open to applicants in Oregon.

📋 Description

• Conduct quality utilization reviews utilizing acquired knowledge and evidence-based guidelines.

• Assess and authorize care based on medical necessity and appropriateness.

• Prepare and evaluate peer review reports, correspondence, addendums, and supplemental reviews.

• Collaborate directly with providers to determine the level, intensity, and duration of care.

• Document findings and assess medical necessity for frequency, intensity, and duration of care.

• Ensure that review consistency and quality meet or surpass industry standards.

• Complete quality reviews within client, federal, state, and URAC-mandated turnaround times.

• Maintain and apply knowledge of URAC and state and federal regulatory requirements.

• Keep accurate utilization review records in the appropriate database.

• Guide Customer Service Representatives to ensure timely delivery of determination letters.

• Assist with client complaints and quality assurance matters.

• Ensure compliance with federal ERISA, URAC, and other state guidelines.

• Provide management with insights and direction regarding compliance concerns.

• Participate in company meetings, training sessions, and ongoing education.

• Carry out other assigned responsibilities.

⛳️ Requirements

• Must possess and maintain an unencumbered Nursing license.

• Experience with UMR or IRO.

• Previous remote work experience.

• Strong understanding of medical terminology, anatomy and physiology, medications, and laboratory values.

• Proficient typist with a minimum speed of 40 W.P.M.

• Comprehensive understanding of HIPAA regulations and compliance.

• Capability to operate a computer, fax machine, copier, scanner, and telephone.

• Familiarity with Microsoft Word, Outlook, Excel, and Internet usage.

• Exceptional communication skills.

• Ability to follow directions and accurately respond to upper management instructions.

• Attention to detail and thoroughness.

• Ability to work independently, prioritize tasks, and manage time effectively.

• Capacity to maintain confidentiality.

• Ability to perform well under pressure or in stressful situations.

• Capability to handle change, delays, or unexpected events appropriately.

• Commitment to adhering to company policies and procedures.

🏝️ Benefits

• 100% remote work from home.

• Flexible work arrangement.

• Medical, vision, and dental benefits.

• Paid time off.

• 401(k) plan.

• Continuing education requirements.