Clinical Quality Assurance Coordinator (32949)

Paycom - ATS; Southfield (MI); Remote; USD 41,000 - 45,000; Full time

Benefits offered by this job

Remote work

Competitive benefits

Paid time off

401k

Job summary

ExamWorks is seeking a Clinical Quality Assurance Coordinator to join our remote team. The role focuses on ensuring peer review reports meet quality standards, regulatory requirements, and client specifications.

The position supports nurses and QA professionals, offering flexible from-home work hours, a 8:30am–5:00pm EST schedule, and opportunities to impact critical reporting accuracy for health plans, TPAs, and managed care organizations.

Qualifications

• Minimum two years of clinical or related field experience.
• Experience in peer review or medical necessity assessments.
• Familiar with CMS guidelines, InterQual, MCG, or payer policies.
• Prior employment with insurance carriers, TPAs, or managed care organizations.
• Strong medical terminology knowledge.
• Must be able to compute rates and percentages and type 40 WPM.

Responsibilities

• Perform quality assurance review of peer review reports and addenda.
• Provide clear evidence-based rationales for recommendations.
• Ensure client instructions are followed and questions addressed.
• Cite current references from reputable journals.
• Ensure reports are high quality and compliant with standards.
• Verify credentials and signatures are accurate on reports.
• Communicate with Peer Reviewer for clarifications when needed.
• Assist in resolution of client complaints and QA issues.
• Adhere to ERISA and state mandates.
• Support management with quality and policy compliance.
• Promote efficient use of company resources.
• Participate in training activities.
• Perform other duties as assigned.

Skills

Peer review experience

Clinical documentation review

CMS guidelines InterQual MCG

Payer policies familiarity

Insurance/TPA experience

Education

High school diploma

Tools

Microsoft Word

Outlook

Excel

Internet

Job description

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? ExamWorks 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.

We are targeting nurses with:

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

Why This Role Rocks:

• 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

Responsibilities may include:

• 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.

Qualifications:

• 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, InterQual, 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, including but not limited to Microsoft Word, Outlook, Excel, and the Internet.
• Must possess excellent skills in English usage, grammar, punctuation and style.
• Ability to follow instructions and respond to upper managements’ directions accurately.
• Demonstrates accuracy and thoroughness. Looks for ways to improve and promote quality and monitors own work to ensure quality is met.
• Must demonstrate exceptional communication skills by conveying necessary information accurately, listening effectively and asking questions where clarification is needed.
• Must be able to work independently, prioritize work activities and use time efficiently.
• Must be able to maintain confidentiality.

Company Background

ExamWorks is a leading provider of innovative healthcare services including independent medical examinations, peer reviews, bill reviews, Medicare compliance, case management, record retrieval, document management and related services. Our clients include property and casualty insurance carriers, law firms, third-party claim administrators and government agencies that use independent services to confirm the veracity of claims by sick or injured individuals under automotive, disability, liability and workers' compensation insurance coverages.

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.

Equal Opportunity Employer - Minorities/Females/Disabled/Veterans

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