Clinical Quality Assurance Coordinator

Are you a detail-oriented clinical professional ready to ensure quality and accuracy in healthcare reviews? Join our team as a Clinical Quality Assurance Coordinator and play a critical role in upholding the integrity, compliance, and excellence of peer review processes. In this role, you will combine clinical knowledge with analytical precision to drive quality outcomes and support healthcare decision-making.

As a Clinical Quality Assurance Coordinator
, you will be responsible for conducting thorough reviews of peer review reports and related documentation to ensure accuracy, compliance, and adherence to regulatory and client standards. This role requires strong clinical knowledge, attention to detail, and the ability to assess medical documentation for completeness, consistency, and quality.

• 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 only to 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.

• 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.

LPN/LVN/RN may be required based on business needs.

• 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…