Clinical Quality Assurance Coordinator (100% Remote)

• 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.
• Perform other duties as assigned.

High school diploma or equivalent 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: workers' compensation, no-fault, liability, and/or disability.

• Must have strong knowledge of medical terminology, anatomy and physiology, medications and laboratory values.
• Must be able to add, subtract, multiply, and divide in all units of measure, using whole numbers and decimals; Ability to compute rates and percentages.
• 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.