MR/PI Coordinator I

Job Summary

Captures and maintains operational activities related to medical review and program integrity processes.

Essential Functions

• Implements, revises, and removes claims system edits.
• Works within the Medicare claims processing systems to monitor the status of UPIC initiated edits.
• Sends out correspondence such as educational letters, prepay notification letters, and suspension correspondence.
• Responds to client inquiries via written or verbal communications.
• Makes and reviews reports showing the results of system edits and presents these findings at Prepay Committee Meetings.
• Communicates with the UPIC legal team, RFI Coordinator, and Law Enforcement to manage the transfer of case/investigation information.
• Works with the UPIC legal team in response to FOIAs, RFIs, ALJ Hearings, Congressional Complaints, and other related activities.
• Monitors and creates reports related to the results of upper level appeals.
• Monitors and creates reports indicating monitoring of identified administrative actions.
• Attends UPIC Medical Review meetings and updates tracking systems with meeting information.
• Captures and manages the transition of workloads, and serves as the interface with other entities.
• Provides training and technical advice to team members.
• Collaborates with Quality Director/Officer on ISO initiatives to improve operational systems, processes, and policies.

Education & Work Experience

• Minimum High School Diploma or GED required.
• 0 - 2 years of experience required; 2 - 4 years preferred.

Qlarant is an Equal Opportunity Employer

of Minorities, Females, Protected Veterans, and Individuals with Disabilities.

About Qlarant

Qlarant is a not-for-profit corporation that partners with public and private sectors to create high quality, safe, and efficient delivery of health care and human services programs. We have multiple lines of business including population health, utilization review, managed care organization quality review, and quality assurance for programs serving individuals with developmental disabilities. Qlarant is also a national leader in fighting fraud, waste and abuse for large organizations across the country. In addition, our Foundation provides grant opportunities to those with programs for underserved communities. Best People, Best Solutions, Best Results