Clinical Quality Assurance Specialist

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

📋 Description

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

• Validate that recommendations and decisions are backed by clear, concise, evidence-based clinical reasoning.

• Ensure that client instructions, specifications, and case inquiries are comprehensively addressed.

• Review clinical citations and references for accuracy, relevance, and timeliness.

• Confirm that reports adhere to standards of professionalism, quality, formatting, and presentation.

• Verify that appropriate physician specialty reviews are conducted in accordance with client requirements and state regulations.

• Ensure that reviewer attestations, provider credentials, signatures, and conflict-of-interest disclosures are properly documented.

• Identify inconsistencies in reports and collaborate with peer reviewers for clarifications, corrections, or modifications.

• Assist in resolving client issues and quality assurance challenges.

• Ensure compliance with federal ERISA regulations, state mandates, and internal compliance standards.

• Provide feedback on consultant quality, compliance, and availability to leadership.

• Engage in training, educational programs, and quality improvement initiatives.

• Support additional projects and responsibilities as assigned.

⛳️ Requirements

• A current, active RN or LPN license is mandatory.

• Strong clinical expertise and a solid understanding of medical terminology and healthcare documentation are essential.

• Exceptional attention to detail and analytical abilities are required.

• Capability to work independently and effectively manage priorities is crucial.

• Strong written and verbal communication skills are necessary.

• A reliable, organized, and self-driven professional is preferred.

• CPC certification is advantageous.

• Experience in medical coding or healthcare documentation review is preferred.

• Prior experience in quality assurance, utilization review, peer review, case management, or clinical compliance is desirable.

• Knowledge of ERISA, regulatory compliance, and healthcare quality standards is favored.

• Candidates with entry-level to early-career experience are encouraged to apply.

• This is a contract-to-hire position located in Rockford, Illinois.

🏝️ Benefits

• Medical, dental & vision coverage.

• Critical Illness, Accident, and Hospital insurance.

• 401(k) Retirement Plan with options for pre-tax and Roth post-tax contributions.

• Voluntary Life Insurance and AD&D for both employees and their dependents.

• Short-term and long-term disability coverage.

• Health Spending Account (HSA) availability.

• Transportation benefits provided.

• Employee Assistance Program access.

• Paid Time Off/Leave options including PTO, Vacation, or Sick Leave.

• Opportunities for professional growth and development.

• Join a collaborative and mission-focused healthcare team.

• This is a non-bedside role.

• Gain exposure to quality assurance and clinical compliance processes.

• Acquire valuable experience in peer review and healthcare quality management.