Utilization Review, Quality Assurance Specialist

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

📋 Description

• Assess clinical information provided and prepare or review a variety of reports, which may include: Medical Record Reviews, Medical Record Chronologies, Provider Bill Reviews, Coding Reviews, Hospital Bill Reviews, Lists of Missing Records, Medical Bill Apportionments, Mock Billing Invoices, and Medical Summary Statements.

• Conduct quality assurance evaluations of peer review reports, correspondences, addendums, or supplemental reviews to ensure compliance with company standards regarding content, clarity, evidence-based rationale, formatting, and professional presentation.

• Confirm that all client instructions and specifications are adhered to, all inquiries are addressed, and all recommendations or conclusions are backed by clear, concise, and evidence-based rationales.

• Ensure each review includes appropriate clinical citations where necessary, and verify that all references cited are up-to-date and sourced from reputable medical journals and publications.

• Detect inconsistencies within reports and reach out to the reviewer for necessary clarifications, modifications, or corrections.

• Aid in resolving customer complaints and quality assurance matters as needed.

• Ensure compliance with all federal ERISA regulations and relevant state mandates.

• Provide continuous feedback and suggestions to management regarding consultant performance, quality trends, and adherence to internal and client-specific requirements.

• Participate in the creation and execution of policies and procedures aimed at enhancing efficiency and quality across operations.

• Lead and conduct both formal and informal training sessions—individually or in groups—that encourage high-quality utilization review practices and reinforce company standards.

• Create and document new or enhanced operational processes to support ongoing improvement.

• Advocate for the effective and efficient use of company resources in all responsibilities.

• Engage in or lead various continuing education and training initiatives related to clinical knowledge, industry standards, and company processes.

• Execute additional duties as assigned.

⛳️ Requirements

• Must possess and maintain a Registered Nursing License.

• Strong knowledge of group health/criteria sets, leadership, and change management.

• Must have a solid understanding of medical terminology, anatomy and physiology, treatment protocols, medications, and laboratory values.

• Proficient in Microsoft Office Suite, Outlook, internet navigation, and general office equipment.

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

• Capable of working independently, prioritizing tasks, and managing time effectively in a fast-paced environment.

• Demonstrate accuracy, thoroughness, and a commitment to producing high-quality work; actively monitor personal performance and seek ways to improve.

• Ability to show flexibility and maintain composure under pressure or in stressful situations; adapts well to change and fosters a positive team atmosphere.

• Must maintain confidentiality at all times.

• Ability to adhere to all company policies and procedures at the time of hire and as they may evolve or be introduced in the future.

🏝️ Benefits

• Medical

• Vision

• Dental

• Paid time off

• 401k