Utilization Review & Quality Assurance Specialist (32449)

Responsibilities

• Evaluate clinical information received, write and/or review various reports including, but not limited to: Medical Record Reviews, Medical Record Chronologies, Provider Bill Reviews, Coding Reviews, Hospital Bill Reviews, List of Missing Records, Medical Bill Apportionments, Mock Billing Invoice and Medical Summary Statements.
• Perform quality assurance reviews of peer review reports, correspondences, addendums or supplemental reviews to ensure they meet company standards for content, clarity, evidence-based rationale, formatting, and professional presentation.
• Ensure all client instructions and specifications have been followed, all questions have been answered, and all recommendations or determinations are supported by clear, concise, and evidence-based rationales.
• Verify that each review includes appropriate clinical citations when applicable, and ensure all references cited are current and obtained from reputable medical journals and publications.
• Identify inconsistencies within reports and contact the reviewer to obtain clarifications, modifications, or corrections needed.
• Aid in the resolution of customer complaints and quality assurance issues as appropriate.
• Ensure all federal ERISA and applicable state mandates are adhered to.
• Provide ongoing feedback and recommendations to management regarding consultant performance, quality trends, and compliance with internal and client specific requirements.
• Participate in or lead various continuing education and training activities related to clinical knowledge, industry standards, and company processes.
• Develop and lead formal and informal training sessions - individually or in groups - that promote high-quality utilization review practices and reinforce company standards.
• Develop and document new or improved operational processes to support continuous improvement.
• Promote effective and efficient utilization of company resources across all responsibilities.
• Participate in or lead various continuing education and training activities related to clinical knowledge, industry standards, and company processes.

Qualifications

• Must hold and maintain a Registered Nursing License.
• Strong knowledge of group health/criteria sets/leadership/change management.
• Must have strong understanding of medical terminology, anatomy and physiology, treatment protocols, medications and laboratory values.
• Must be proficient in Microsoft Office Suite, Outlook, internet navigation and general office equipment.
• Able to follow instructions and respond to upper managements’ directions accurately.
• Able to work independently, prioritize tasks, and manage time efficiently in a fast-paced environment.
• Able to demonstrate accuracy, thoroughness, and commitment to producing high quality work; actively monitor own performance and seek opportunities for improvement.
• Able to demonstrate flexibility and remain composed under pressure or in stressful conditions; adapts well to change and promotes a positive team environment.
• Must be able to maintain confidentiality.
• Able to follow all company policies and procedures in effect at time of hire and as they may change or be added from time to date.

Benefits

ExamWorks offers a fast-paced team atmosphere with competitive benefits (medical, vision, dental), paid time off, and 401k.