Clinical Quality Assurance Coordinator (33045)

MES Solutions; United States; On-site; USD 45,000 - 65,000; Full time

Job summary

MES Solutions is seeking a Clinical Quality Assurance Coordinator to ensure the quality and integrity of case reports, in line with client contracts and regulatory standards.

The role supports the QA department by handling questions, providing evidence-based rationales, and ensuring proper documentation.

Qualifications

• High school diploma or equivalent required; 2+ years clinical or related field experience preferred.
• Knowledge of the insurance industry, preferably claims management.
• LPN/LVN/RN may be required based on business needs.
• Strong knowledge of medical terminology, anatomy and physiology, medications and laboratory values.
• Must be a qualified typist with a minimum of 40 WPM.
• Knowledge of HIPAA regulations and compliance.

Responsibilities

• Perform quality assurance review of peer review reports, correspondences, addendums or supplemental reviews.
• Ensure evidence-based rationales support recommendations and determinations.
• Verify client instructions and specifications are followed; address questions.
• Ensure reports cite current, reputable medical sources.
• Maintain high quality content and professional appearance of reports.
• Document appropriate board specialty review per client specs.
• Verify reviewer attestation and absence of conflicts of interest.
• Ensure provider credentials and signatures are properly applied.
• Identify inconsistencies and seek clarifications or corrections.
• Assist in resolution of client complaints and QA issues.
• Adhere to ERISA and state mandates.
• Provide insights to management on consultant quality and compliance.
• Promote efficient use of company resources.
• Participate in training activities.

Skills

Medical terminology

Anatomy & physiology

HIPAA compliance

Typing speed

Education

High school diploma

LPN/LVN/RN license (may be required)

Tools

Microsoft Word

Microsoft Excel

Job description

Clinical Quality Assurance Coordinator (33045)

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 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

MINIMUM REQUIRED QUALIFICATIONS

Education and/or Experience

High school diploma or equivalent required. A minimum of two years clinical or related field experience; or equivalent combination of education and experience preferred. Knowledge of the insurance industry, preferably claims management relative to one or more of the following categories: workers' compensation, no-fault, liability, or disability preferred.

Certificates, Licenses, Registrations

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

ESSENTIAL COMPETENCIES

QUALIFICATIONS

• 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.
• 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.

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

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

This position generally consists of:

• 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.
• Ability to travel to different floors of the office or other locations.
• Ability to move throughout the office.
• Occasionally lifting and/or carrying up to 10 lbs.
• Occasionally pushing/pulling up to 10 lbs.
• Occasionally subject to bending, squatting or twisting.

WORK ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Extended hours are occasionally required beyond the regular eight (8) hour work day.
• The noise level in the work environment is usually moderate.