Summary
AllMed provides clinical decision-making and utilization management solutions to payer and provider organizations. The Clinical Quality Assurance Coordinator performs quality utilization reviews, evaluates medical necessity, maintains regulatory compliance, documents findings, and supports timely delivery and resolution of review-related issues.
Responsibilities
- 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
Skills
- 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
Qualifications
Must Haves
- 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
Benefits
- 100% remote opportunity with the flexibility of working from home
- Medical benefits
- Vision benefits
- Dental benefits
- Paid time off
- 401k