Clinical Quality Assurance Coordinator (32945)

AllMed Medical Management; Portland (OR); Remote; USD 70,000 - 100,000; Full time

Benefits offered by this job

Medical benefits

Vision benefits

Dental benefits

Paid time off

401k

Job summary

AllMed Medical Management is seeking a Clinical Quality Assurance Coordinator to support 100% remote utilization review services. The role focuses on applying evidence-based guidelines to determine medical necessity and ensure accuracy and regulatory compliance across reviews.

The ideal candidate has nursing licensure and experience with URAC or IRO processes, strong medical knowledge, and the ability to work independently within Pacific Time business hours.

Qualifications

• Must hold and maintain an unencumbered Nursing license.
• URAC or IRO experience preferred.
• Remote work experience required.
• Strong knowledge of medical terminology, anatomy and physiology, medications and labs.
• Proficient typist and able to type at least 40 WPM.
• Knowledge of HIPAA regulations and compliance.
• Ability to operate standard office equipment and computers.
• Proficient with MS Word, Outlook, Excel and web resources.
• Excellent communication skills and attention to detail.
• Ability to follow directions and manage priorities independently.
• Maintain confidentiality and promote a positive team environment.

Responsibilities

• Perform quality utilization reviews using evidence-based guidelines.
• Collaborate with providers to determine level, intensity, and duration of care.
• Document findings and evaluate medical necessity for care frequency and length.
• Ensure reviews meet industry standards and client obligations.
• Adhere to turnaround times per client, URAC, and regulatory requirements.
• Maintain accurate utilization review records in the database.
• Coordinate with Customer Service to ensure timely delivery of determinations.
• Assist in resolving client complaints and quality issues.
• Support company policies and regulatory compliance in all reviews.
• Participate in meetings, training, and ongoing education.

Skills

Medical terminology

HIPAA compliance

Communication skills

Independent work

Time management

Education

Nursing license

Tools

Microsoft Word

Outlook

Excel

Internet

Job description

Join Our Team as a Clinical Quality Assurance Coordinator!

Are you detail-driven, passionate about quality, and excited to make a meaningful impact in healthcare? AllMed is looking for a motivated Clinical Quality Assurance Coordinator to help us ensure excellence in every review we deliver.

This is a 100% remote opportunity that offers the flexibility of working from home. The role primarily supports Pacific Time Zone operations, with schedules falling within business hours of 5:00am to 5:30pm PST. Candidates should be comfortable working a set schedule within that timeframe, and occasional weekend coverage may be required based on business needs.

In this role, you'll play a critical part in delivering high-quality utilization review services. You'll review and approve care based on evidence-based guidelines, ensuring medical necessity and appropriateness. Your work will uphold the highest standards of accuracy, integrity, and compliance with client agreements, regulatory requirements, and federal/state mandates.

Responsibilities may include:

• Perform quality utilization review through the use of acquired knowledge and application of evidenced based guidelines for peer review reports, correspondences, addendums and/or supplemental reviews.
• Work directly with providers to identify level, intensity and duration of care.
• Document findings, continue to evaluate medical necessity for frequency, intensity and length of required care.
• Assure that the consistency and quality of reviews meets or exceeds industry standards.
• Work to ensure quality reviews are completed within the required client, federal and state or URAC mandated turnaround times.
• Maintain and apply knowledge of URAC and other state and federal regulatory requirements.
• Maintain accurate record of Utilization Reviews within the appropriate database.
• Direct Customer Service Representatives to ensure timely delivery of determination letters.
• Assist in resolution of client complaints and/or quality assurance issues as needed.
• Ensure all quality assurance standards and federal ERISA, URAC, and/or other state guidelines are adhered to at all times.
• Provide insight and direction to management on any compliance concerns regarding products, company policies and procedures and/or client specifications.
• Participate in company meetings, training activities and continuing education requirements.
• Perform all other duties as assigned.

If you thrive in a collaborative environment and love contributing to high-quality clinical outcomes, we'd love to meet you!

Qualifications

• Must hold and maintain an unencumbered Nursing license.
• UMR or IRO experience.
• Remote work experience
• 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 managements' directions accurately.
• Must demonstrate accuracy and thoroughness. Look for ways to improve and promote quality and monitors 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.

AllMed provides clinical decision making and utilization management solutions to leading payer and provider organizations. We work closely with your team toward a shared vision of healthcare that delivers the highest quality, values patient experience, and ensures both appropriate care and utilization of health-related services.

AllMed offers a fast-paced team atmosphere with competitive benefits (medical, vision, dental), paid time off, and 401k.

Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, pregnancy, genetic information, disability, status as a protected veteran, or any other protected category under applicable federal, state, and local laws.