Clinical Quality Assurance Coordinator

Job Details:

Job Location:

Southfield, MI 48076, Position Type:
Full Time, Salary Range: $30.00 - $33.00 Hourly, Travel Percentage:
None, Craving a New Adventure? Flex Your Clinical Skills Right from Your Couch!

Are you a Nurse (LPN, LVN or RN) seeking a role that challenges you, helps you grow, and lets you work from the comfort of your own home? Exam Works has the perfect opportunity for you!

We’re looking for a Clinical Quality Assurance Coordinator to join our team! In this role, you’ll ensure Peer Review case reports meet the highest standards of quality, integrity, and compliance with client agreements, regulatory guidelines, and federal/state mandates.

• experience with peer review, clinical documentation review, or medical necessity assessments.
• familiarity with CMS guidelines, Inter Qual, Milliman/MCG, or payer policies.
• prior employment with insurance carriers, TPAs, or managed care organizations.

• 100% Remote – Enjoy the flexibility of working from home!
• Impactful Work – You’ll play a key role in ensuring the quality and compliance of critical reports.
• Schedule – Monday to Friday; 8:30am-5:00pm EST

• 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 contacts 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 with aminimum of two years clinical or related field experience; or equivalent combination of education and experience.
• Experience in peer review, clinical documentation review, or medical necessity assessments.
• Familiarity with CMS guidelines, Inter Qual, Milliman/MCG, or payer policies.
• Prior employment with insurance carriers, TPAs, or managed care organizations.
• 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,…