Clinical Quality Assurance Coordinator
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Job Description
Clinical Quality Assurance Coordinator reviewing utilization decisions for AllMed, which provides clinical decision-making and utilization management solutions. Ensuring evidence-based, compliant, accurate healthcare reviews.
Responsibilities:
- Perform quality utilization reviews using acquired knowledge and evidence-based guidelines
- Review and approve care based on medical necessity and appropriateness
- Prepare and review peer review reports, correspondence, addendums, and supplemental reviews
- Work directly with providers to identify level, intensity, and duration of care
- Document findings and evaluate medical necessity for frequency, intensity, and length of care
- Ensure review consistency and quality meets or exceeds industry standards
- Complete quality reviews within client, federal, state, and URAC-mandated turnaround times
- Maintain and apply knowledge of URAC and state and federal regulatory requirements
- Maintain accurate utilization review records in the appropriate database
- Direct Customer Service Representatives to ensure timely delivery of determination letters
- Assist with client complaints and quality assurance issues
- Ensure adherence to federal ERISA, URAC, and other state guidelines
- Provide management with insight and direction on compliance concerns
- Participate in company meetings, training activities, and continuing education
- Perform other assigned duties
Requirements:
- Must hold and maintain an unencumbered Nursing license
- UMR or IRO experience
- Remote work experience
- Strong knowledge of medical terminology, anatomy and physiology, medications, and laboratory values
- Qualified typist with a minimum of 40 W.P.M.
- Full understanding of HIPAA regulations and compliance
- Ability to operate a computer, fax, copier, scanner, and telephone
- Knowledge of Microsoft Word, Outlook, Excel, and the Internet
- Exceptional communication skills
- Ability to follow instructions and respond accurately to upper management directions
- Accuracy and thoroughness
- Ability to work independently, prioritize work activities, and use time efficiently
- Ability to maintain confidentiality
- Ability to work well under pressure or stressful conditions
- Ability to manage change, delays, or unexpected events appropriately
- Ability to follow company policies and procedures
Benefits:
- 100% remote work from home
- Flexible work arrangement
- Medical, vision, and dental benefits
- Paid time off
- 401(k)
- Continuing education requirements
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