Clinical Quality Assurance Coordinator

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

📋 Description

• Conduct quality utilization reviews utilizing acquired expertise and evidence-based guidelines for peer review documentation, communications, addendums, and supplementary evaluations.

• Collaborate directly with healthcare providers to ascertain the level, intensity, and duration of care provided.

• Record findings and persistently assess the medical necessity concerning the frequency, intensity, and length of required care.

• Ensure that the consistency and quality of reviews meet or surpass industry standards.

• Complete quality reviews within the stipulated client, federal, state, and URAC-required turnaround times.

• Maintain and implement knowledge of URAC along with other state and federal regulatory mandates.

• Keep precise records for utilization reviews in the designated database.

• Guide Customer Service Representatives to guarantee prompt delivery of determination letters.

• Support in managing client complaints and quality assurance matters.

• Ensure compliance with quality assurance standards, ERISA, URAC, and other state regulations.

• Provide management with insights and direction concerning compliance issues.

• Engage in company meetings, training sessions, and ongoing educational requirements.

• Execute other assigned responsibilities.

⛳️ Requirements

• Must possess and uphold an unencumbered Nursing license.

• Experience with UMR or IRO.

• Prior remote work experience.

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

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

• Comprehensive knowledge of HIPAA regulations and compliance practices.

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

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

• Excellent communication abilities.

• Aptitude to accurately follow instructions and management directives.

• High level of accuracy and attention to detail.

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

• Commitment to maintaining confidentiality.

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

• Competence in handling changes, delays, or unforeseen events appropriately.

• Ability to comply with company policies and procedures.

🏝️ Benefits

• 100% remote opportunity.

• Flexible work-from-home arrangements.

• Medical, vision, and dental insurance coverage.

• Paid time off.

• 401k plan.

• Opportunities for continuing education.