Clinical Quality Assurance Coordinator (32080)

Summary The Clinical Quality Assurance Coordinator is responsible for ensuring case reports are of the highest quality and integrity and in full compliance with client contractual agreements, regulatory agency standards, and federal and state mandates. This position is required to handle quality assurance questions and provide support to the Quality Assurance Department. Essential Job Functions Perform quality assurance review of peer review reports, correspondences, addendums or supplemental reviews. Ensure clear, concise, evidence-based rationales have been provided in support of all recommendations and/or determinations. Ensure that all client instructions and specifications have been followed and that all questions have been addressed. Ensure 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. Ensure the content, format, and professional appearance of the reports are of the highest quality and in compliance with company standards. Ensure the appropriate board specialty has reviewed the case in compliance with client specifications or state mandates and is documented accurately on the case report. Verify that the peer reviewer has attested to only the facts and that no evidence of reviewer conflict of interest exists. Ensure the provider credentials and signature are adhered to the final report. Identify any inconsistencies within the report and contact the Peer Reviewer to obtain clarification, modification, or correction as needed. Assist in resolution of client complaints and quality assurance issues as needed. Ensure all federal ERISA and state mandates are adhered to at all times. Provide 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. Qualifications High school diploma or equivalent required. Minimum of two (2) years of clinical or related experience preferred, or an equivalent combination of education and experience. Knowledge of the insurance industry, including claims management (workers’ compensation, no-fault, liability, or disability), preferred. Certificates, Licenses, Registrations LPN/LVN/RN may be required based on business needs. Essential Competencies 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 have a full understanding of HIPAA regulations and compliance. 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 demonstrate exceptional communication skills. Ability to follow instructions and respond to upper management’s directions accurately. Must demonstrate accuracy and thoroughness. Look for ways to improve and promote quality and monitor own work to ensure quality is met. 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. Ability to follow all company policies and procedures in effect at time of hire and as they may change or be added from time to time. Language / Communication Skills Ability to read, analyze and interpret common correspondence, medical records, and legal contracts and documents. Ability to write clearly and informatively to all required audiences and edit own work for appropriate spelling and grammar. Ability to respond appropriately and professionally to all inquiries or complaints from customers, physicians, regulatory agencies, and/or members of the business community. Ability to effectively present information one‑on‑one or in small groups. Physical Demands Ability to work at a desk or similar office-type furnishings up to 8 hours a day or longer as required by business needs. Ability to operate a computer up to 4 hours at a time. Work Environment Extended hours are occasionally required beyond the regular eight (8) hour work day. Equal Opportunity Employer MES is an Equal Opportunity Employer and affords equal opportunity to all qualified applicants for all positions without regard to protected veteran status, qualified individuals with disabilities and all individuals without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age or any other status protected under local, state or federal laws. #J-18808-Ljbffr MES Solutions