Clinical Quality Assurance Coordinator (32804)

About the role

MES is seeking a Clinical Quality Assurance Coordinator to join our growing team. In this role, you'll dive into medical records, pulling out key details and crafting detailed narrative summaries. Your keen eye for detail will make you an invaluable part of our quality assurance process.

Why you'll love this role

• 100% remote – work from home
• Flexible hours: Monday-Friday with rotating shifts (all ET):
  • 7:00am-3:30pm
  • 8:00am-4:30pm
  • Early shift (2 days): 10:00am-6:30pm (1 day)
  • 12:00pm-8:30pm (2 days)
• Great training – the first 4-6 weeks are designed to set you up for success, with a preferred training schedule of 12:00pm-8:30pm EST
• Employee-first company offering fantastic benefits and incredible growth opportunities

Responsibilities

• Performs quality assurance review of peer review reports, correspondences, addendums or supplemental reviews
• Ensures clear, concise, evidence-based rationales have been provided in support of all recommendations and/or determinations
• Ensures that all client instructions and specifications have been followed and that all questions have been addressed
• Ensures 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
• Ensures the content, format, and professional appearance of the reports are of the highest quality and in compliance with company standards
• Ensure that the appropriate board specialty has reviewed the case in compliance with client specifications and/or state mandates and is documented accurately on the case report
• Verifies that the peer reviewer has attested to only the fact(s) and that no evidence of reviewer conflict of interest exists
• Ensures the provider credentials and signature are adhered to the final report
• Identifies any inconsistencies within the report and contacts the Peer Reviewer to obtain clarification, modification or correction as needed
• Assists in resolution of customer complaints and quality assurance issues as needed
• Ensures all federal ERISA and/or state mandates are adhered to at all times
• Provides insight and direction to management on consultant quality, availability and compliance with all company policies and procedures and client specifications
• Promotes effective and efficient utilization of company resources
• Participates in various educational and/or training activities as required

Qualifications

Education and/or experience:

• High school diploma or equivalent required
• A minimum of two years clinical or related field experience preferred; or equivalent combination of education and experience
• Knowledge of the insurance industry, preferably claims management relative to workers' compensation, no-fault, liability, or disability preferred

Certificates, licenses, registrations:

• LPN/LVN/RN may be required based on business needs

Skills

• 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 general computer, fax, copier, scanner, and telephone
• Knowledgeable of multiple software programs, including but not limited to Microsoft Word, Outlook, Excel, and the Internet
• Exceptional communication skills
• Ability to follow instructions and respond to upper management's directions accurately
• Demonstrates accuracy and thoroughness; looks for ways to improve and promote quality and monitors own work to ensure quality is met
• Ability to work independently, prioritize work activities and use time efficiently
• Ability to maintain confidentiality
• Ability to demonstrate and promote a positive team-oriented environment
• Ability to stay focused and concentrate under normal or heavy distractions
• Ability to work well under pressure and/or stressful conditions
• Ability to manage change, delays, or unexpected events appropriately
• Ability to follow all company policies and procedures