Quality Coordinator

Position Purpose:

Performs advanced (senior-level) quality assurance work. Ensures decision makers adjudicate cases accurately by performing quality audits, reviews, and publishing audit results and conducting meetings, providing coaching, and training on quality. Works under limited supervision, with considerable latitude for the use of initiative and independent judgement.

Essential Responsibilities:

• Oversees, plans, and monitors the quality assurance program.
• Oversees, plans, and audits to ensure timeliness, accuracy, and consistency in reconsideration/dispute resolution decisions.
• Oversees, develops, and identifies individual and collective training opportunities based on audit findings and/or data analysis of reconsiderations/dispute resolution decisions to help improve individual and corporate quality.
• Oversees, plans, prepares, reviews and analyses data to identify problems, trends and improvement opportunities.
• Oversees, plans, and reviews reopened cases and cases from the problem log in order to identify trends and needs for improvement.
• Participates in planning, preparing, and facilitating discussion for regularly scheduled process and program improvement meetings.
• Plans, prepares and facilitates separate quality meetings with decision makers, management, and subcontractors.
• Oversees, plans, and provides consultative assistance to management when improvement opportunities are identified.
• Oversees and designs and improves process workflows to improve efficiency and control unit cost.
• Supports International Organization for Standardization (ISO) certification by interacting with the ISO auditors when surveillance audits are performed by the vendor. May also conduct mock ISO audits for the contract.
• Plans and updates work instructions on an annual basis, or more frequently, as needed.
• Oversees, provides and plans training for new and current staff, including developing and presenting presentations, quality tips, and decision consistency memos.
• Plans and implements an Inter-Reviewer Reliability (IRR) audit program and process that will validate consistency among decision makers or identify areas of improvement.
• Stays abreast of and identifies changes in Medicare/Surprise Billing policy, guidelines, and protocols to ensure needed changes are implemented timely. Plans and maintains a comprehensive log of these changes, determines if there is an impact to existing operations, and distributes the changes as applicable.
• Plans and monitors the electronic mailing software for changes and Comprehensive Error Rate Testing (CERT) reviews to be used for education.
• Oversees, plans, researches and develops responses to staff, appellant and Centers for Medicare and Medicaid Services (CMS) inquiries.
• Oversees and assists with answering subcontractor inquiries, correspondence, and contractor inquiries.

• May supervise, train, and evaluate project work activities and personnel.

• May submit monthly newsletter to staff on the state of the organization’s quality performance.
• May plan, research and analyze Administrative Law Judge (ALJ) remands, overturned cases and root cause analysis.
• Participates in special projects and performs other duties as assigned.

Minimum Qualifications

Education

• Associate's degree or 60 or more credit hours towards a Bachelor’s degree from an accredited college or university in healthcare or related discipline
  • Additional Medicare appeals or clinical experience in a healthcare setting may be substituted for Associate’s degree on a year per year basis. (Experience requirements may be satisfied by full-time experience or the prorated part-time equivalent.)

Experience

• Five (5) years medical dispute, Medicare appeals or clinical experience in a healthcare setting
• Two (2) years of training
• Experience directly relevant to the specific task order or project
• Healthcare Professional with demonstrated experience writing or making medical necessity decisions
• Nursing, Physical Therapy, Respiratory Therapy or Occupational Therapy experience

Knowledge, Skills and Abilities

Thorough knowledge of

• Research techniques
• Medical terminology
• Medicare program, including coverage and payment rules
• Medicare regulations, claims administration, and medical review processes
• Applicable laws, rules and regulations

Expert skill in

• Analyzing complex problems and developing, recommending and implementing effective solutions
• Developing and giving presentations and trainings
• Establishing plans and setting objectives and goals that support overall business strategy/results; anticipating and adjusting for problems/roadblocks
• Group and meeting facilitation
• Maintaining effective working relationships with individuals and groups
• Preparing correspondence/documents using correct spelling, grammar and punctuation; proofreading and reviewing documents for clarity and consistency
• Prioritizing and organizing work assignments
• Researching, analyzing and interpreting policies and state and federal laws and regulations
• The use of personal computers and applicable programs, applications and systems

Ability to

• Provide leadership across multiple contracts on a large scale project
• Multitask and meet deadlines
• Exercise logic and reasoning to define problems, establish facts and draw valid conclusions
• Make decisions that support business objectives and goals
• Identify and resolve problems or refer issues appropriately
• Communicate effectively verbally and in writing
• Adapt to the needs of internal and external customers
• Show integrity and ethical behavior; respect confidentiality, business ethics and organizational standards
• Assures compliance with company policies and procedures, including regulatory, contractual and accreditation entities

Why J29?

J29 is an employee centric Federal Contractor that focuses on creating health and IT solutions for the better of the community. Making company culture the main priority ensures employees satisfaction and retention. We believe in empowering employees to do great things. When you invest in your people, and focus on creating a healthy work life balance, then your employees will take care of your customers and make sure they are happy. One of our sayings is “Work Hard and Be Nice to People” – it really is that simple.

J29 Solutions

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EEO Statement

J29, Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.