Clinical Quality Assurance Coordinator

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

📋 Description

• Conduct quality assurance evaluations of peer review reports, correspondence, addendums, and supplemental reviews.

• Ensure that recommendations and determinations are supported by clear, concise, and evidence-based rationales.

• Confirm that client instructions, specifications, and inquiries are adequately addressed.

• Validate that clinical citations and references are up-to-date and reputable.

• Guarantee that the content, format, and professional presentation of reports adhere to company standards.

• Ensure that appropriate board specialty review and documentation align with client specifications or state mandates.

• Verify peer reviewer attestations and ensure there are no conflicts of interest.

• Confirm that provider credentials and signatures are included in the final reports.

• Identify discrepancies in reports and reach out to peer reviewers for clarification or correction.

• Assist in managing client complaints and addressing quality assurance concerns.

• Ensure adherence to federal ERISA regulations and state mandates.

• Provide management with insights regarding consultant quality, availability, and compliance.

• Encourage the effective and efficient utilization of company resources.

• Engage in educational and training initiatives.

• Undertake additional assigned responsibilities.

⛳️ Requirements

• A high school diploma or equivalent is required.

• A minimum of two years of clinical or related field experience, or a comparable combination of education and experience.

• Experience in peer review, clinical documentation review, or assessments of medical necessity.

• Familiarity with CMS guidelines, InterQual, Milliman/MCG, or payer policies.

• Previous employment with insurance carriers, TPAs, or managed care organizations.

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

• Ability to perform arithmetic with whole numbers and decimals, including computing rates and percentages.

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

• Capable of operating a computer, fax machine, copier, scanner, and telephone.

• Proficient in Microsoft Word, Outlook, Excel, and the Internet.

• Excellent command of English usage, grammar, punctuation, and style.

• Ability to accurately follow instructions.

• Skills in accuracy, thoroughness, and quality monitoring.

• Outstanding communication abilities.

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

• Ability to maintain confidentiality.

🏝️ Benefits

• 100% remote work from home.

• Medical, vision, and dental benefits.

• Paid time off.

• 401k plan.

• Fast-paced team environment.

• Monday to Friday schedule, from 8:30 am to 5:00 pm EST.