Remote Clinical Quality Assurance Coordinator

January 2

🌲 Oregon – Remote

Although this job is listed in Oregon, this company may be open to hiring remote in other states.

⏰ Full Time

🟢 Junior

🟡 Mid-level

🔧 QA Engineer (Quality Assurance)

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AllMed Healthcare Management

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AllMed Healthcare Management is a company that focuses on providing healthcare management solutions. They offer client and reviewer portals to facilitate seamless interactions within their healthcare services, ensuring efficient communication and support for users. AllMed is dedicated to improving healthcare processes and enhancing user experience through their technology-driven platforms.

Independent Medical Review • Utilization Review • External Peer Review • Specialty Matched Pre-authorizations • Appeals

51 - 200 employees

Founded 1995

⚕️ Healthcare Insurance

☁️ SaaS

📋 Description

• Responsible for ensuring that Peer Review case reports meet the highest standards of quality, integrity, and compliance with client agreements, regulatory guidelines, and federal/state mandates. • 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. • Promote effective and efficient utilization of company resources. • Participate in various educational and or training activities as required.

🎯 Requirements

• Active nursing license required. • A minimum of two years clinical or related field experience; or equivalent combination of education and experience. • Knowledge of the insurance industry preferably claims management relative to one or more of the following categories: utilization management, coding, claims review, clinical appeals. • Must have strong knowledge of medical terminology, anatomy and physiology, medications and laboratory values. • 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 knowledgeable of multiple software programs, including but not limited to Microsoft Word, Outlook, Excel, and the Internet. • Must possess excellent skills in English usage, grammar, punctuation and style. • 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 demonstrate exceptional communication skills by conveying necessary information accurately, listening effectively and asking questions where clarification is needed. • Must be able to work independently, prioritize work activities and use time efficiently. • Must be able to maintain confidentiality. • Must be able to demonstrate and promote a positive team -oriented environment. • Must be able to stay focused and concentrate under normal or heavy distractions. • Must be able to work well under pressure and or stressful conditions. • Must possess the ability to manage change, delays, or unexpected events appropriately.

🏖️ Benefits

• Competitive benefits (medical, vision, dental) • Paid time off • 401k