Clinical Quality Assurance Coordinator (32277)

Responsibilities

• Perform quality assurance review of peer review reports, correspondences, addendums or supplemental reviews.
• Ensure clear, concise, evidence-based rationales have been provided in support of all recommendations and/or determinations.
• Ensure that all client instructions and specifications have been followed and that all questions have been addressed.
• Ensure each review is supported by clinical citations and references when applicable and verifies that all references cited are current and obtained from reputable medical journals and/or publications.
• Ensure the content, format, and professional appearance of the reports are of the highest quality and in compliance with company standards.
• Ensure the appropriate board specialty has reviewed the case in compliance with client specifications or state mandates and is documented accurately on the case report.
• Identify any inconsistencies within the report and contact the Peer Reviewer to obtain clarification, modification or correction as needed.
• Afford assistance in resolving client complaints and quality assurance issues as needed.
• Ensure all federal ERISA and state mandates are adhered to at all times.
• Provide insight and direction to management on consultant quality, availability and compliance with all company policies and procedures and client specifications.
• Promote effective and efficient utilization of company resources.
• Participate in various educational and or training activities as required.
• Perform other duties as assigned.

Qualifications

• A high school diploma or equivalent with a minimum of two years clinical or related field experience; or equivalent combination of education and experience.
• Experience in peer review, clinical documentation review, or medical necessity assessments.
• Familiarity with CMS guidelines, InterQual, Milliman/MCG, or payer policies.
• Prior employment with insurance carriers, TPAs, or managed care organizations.
• Strong knowledge of medical terminology, anatomy and physiology, medications and laboratory values.
• Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers and decimals; compute rates and percentages.
• Knowledgeable of multiple software programs, including but not limited to Microsoft Word, Outlook, Excel, and the Internet.
• Excellent communication skills by conveying necessary information accurately, listening effectively and asking questions where clarification is needed.
• Ability to work independently, prioritize work activities and use time efficiently.
• Exceptional communication skills by conveying necessary information accurately, listening effectively and asking questions where clarification is needed.
• Knowledgeable of multiple software programs, including but not limited to Microsoft Word, Outlook, Excel, and the Internet.
• Ability to follow instructions and respond to upper managements’ directions accurately.
• Demonstrates accuracy and thoroughness. Looks for ways to improve and promote quality and monitors own work to ensure quality is met.
• Must be a qualified typist with a minimum of 40 W.P.M.
• Must be able to operate a general computer, fax, copier, scanner, and telephone.
• Must be able to work independently, prioritize work activities and use time efficiently.
• Must be able to maintain confidentiality.