Join Our Team as a Clinical Quality Assurance Coordinator!
Are you detail-driven, passionate about quality, and excited to make a meaningful impact in healthcare? AllMed is looking for a motivated Clinical Quality Assurance Coordinator to help us ensure excellence in every review we deliver.
This is a 100% remote opportunity that offers the flexibility of working from home. The role primarily supports Pacific Time Zone operations, with schedules falling within business hours of 5:00am to 5:30pm PST. Candidates should be comfortable working a set schedule within that timeframe, and occasional weekend coverage may be required based on business needs.
In this role, you’ll play a critical part in delivering high-quality utilization review services. You’ll review and approve care based on evidence-based guidelines, ensuring medical necessity and appropriateness. Your work will uphold the highest standards of accuracy, integrity, and compliance with client agreements, regulatory requirements, and federal/state mandates.
Responsibilities may include:
- Perform quality utilization review through the use of acquired knowledge and application of evidenced based guidelines for peer review reports, correspondences, addendums and/or supplemental reviews.
- Work directly with providers to identify level, intensity and duration of care.
- Document findings, continue to evaluate medical necessity for frequency, intensity and length of required care.
- Assure that the consistency and quality of reviews meets or exceeds industry standards.
- Work to ensure quality reviews are completed within the required client, federal and state or URAC mandated turnaround times.
- Maintain and apply knowledge of URAC and other state and federal regulatory requirements.
- Maintain accurate record of Utilization Reviews within the appropriate database.
- Direct Customer Service Representatives to ensure timely delivery of determination letters.
- Assist in resolution of client complaints and/or quality assurance issues as needed.
- Ensure all quality assurance standards and federal ERISA, URAC, and/or other state guidelines are adhered to at all times.
- Provide insight and direction to management on any compliance concerns regarding products, company policies and procedures and/or client specifications.
- Participate in company meetings, training activities and continuing education requirements.
- Perform all other duties as assigned.
If you thrive in a collaborative environment and love contributing to high-quality clinical outcomes, we’d love to meet you!
- Must hold and maintain an unencumbered Nursing license.
- UMR or IRO experience.
- Remote work experience
- Must have strong knowledge of medical terminology, anatomy and physiology, medications and laboratory values.
- Must be a qualified typist with a minimum of 40 W.P.M
- Must have a full understanding of HIPAA regulations and compliance.
- Must be able to operate a general computer, fax, copier, scanner, and telephone.
- Must be knowledgeable of multiple software programs, including but not limited to Microsoft Word, Outlook, Excel, and the Internet.
- Must demonstrate exceptional communication skills.
- Ability to follow instructions and respond to upper managements’ directions accurately.
- Must demonstrate accuracy and thoroughness. Look for ways to improve and promote quality and monitors own work to ensure quality is met.
- Must be able to work independently, prioritize work activities and use time efficiently.
- Must be able to maintain confidentiality.
- Must be able to demonstrate and promote a positive team -oriented environment.
- Must be able to stay focused and concentrate under normal or heavy distractions.
- Must be able to work well under pressure and or stressful conditions.
- Must possess the ability to manage change, delays, or unexpected events appropriately.
- Ability to follow all company policies and procedures in effect at time of hire and as they may change or be added from time to time.