IDRE Quality Specialist

North Haven Solutions; EE. UU.; Híbrido; USD 65.000 - 95.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Medical, dental, and vision coverage

401k with company match

Remote workspace equipment stipend

Paid time off

Voluntary life insurance options

Other voluntary benefits

Descripción de la vacante

North Haven Government Services Solutions is seeking an IDRE QA Specialist to join our Operations team. This role ensures accuracy, completeness, and timely delivery of CMS reports within the IDR process.

The QA Specialist coordinates with customers, reviewers, and management to resolve questions and deficiencies while upholding HIPAA/PHI protections. The ideal candidate is highly organized, detail-oriented, and capable of managing multiple priorities in a deadline-driven environment.

Formación

• An LPN, Associate’s or Bachelor’s degree is preferred; relevant professional experience may be considered.
• Business experience in healthcare and/or insurance settings is preferred.

Responsabilidades

• Review reviewer reports for accuracy, completeness, and adherence to customer requirements, company standards, and applicable clinical guidelines.
• Coordinate and communicate effectively with customers, reviewers, and management to resolve questions, address deficiencies, and facilitate timely report completion.
• Ensure reports meet established quality standards and are submitted to CMS within required deadlines.
• Identify discrepancies, missing information, and opportunities for improvement throughout the review process.
• Maintain a strong understanding of company processes, quality expectations, and applicable IDRE requirements.
• Contribute to continuous process improvement initiatives designed to enhance quality, efficiency, and turnaround times.
• Work collaboratively with the Operations team to support the company’s continued growth and operational success
• Evaluates the Quality of the dispute rationale/ determination to ensure that all requirements have been met in compliance with internal and CMS guidelines.
• Follow up with the arbiters for any pertinent and missing information
• Assess whether the rationale is logical and the conclusions are based on sound assumptions
• Maintain professionalism and courtesy when responding to emails and other communications, while ensuring all communications involving HIPAA and PHI are handled appropriately, securely, and in accordance with applicable privacy and confidentiality requirements.

Conocimientos

Detail-oriented

Strong communication skills

Deadline-driven

Problem-solving abilities

Accuracy-focused

HIPAA and PHI handling

Educación

LPN

Associate’s degree

Bachelor’s degree

Descripción del empleo

IDRE QA Specialist

North Haven Government Services Solutions

North Haven Government Services Solutions is seeking a skilled and detail-oriented IDRE QA Specialist to join our growing Operations team. This is an important role within our Independent Dispute Resolution (IDR) process, ensuring the accuracy, completeness, and timely delivery of reports to the Centers for Medicare & Medicaid Services (CMS).

The QA Specialist serves as a key point of coordination between customers, reviewers, and management, helping ensure that each completed reviewer report meets established requirements and is delivered within required timeframes.

What We’re Looking For

The ideal candidate is highly organized, detail-oriented, and able to manage multiple priorities in a deadline-driven environment. Strong communication skills, sound judgment, problem-solving abilities, and a commitment to accuracy are essential.

North Haven Solutions values innovation, collaboration, accountability, and integrity. We offer an engaging work environment where your contributions make a meaningful difference. If you are looking for a challenging and rewarding opportunity with room for professional growth, we invite you to help us deliver excellence without exception.

Key Responsibilities

Review reviewer reports for accuracy, completeness, and adherence to customer requirements, company standards, and applicable clinical guidelines.

Coordinate and communicate effectively with customers, reviewers, and management to resolve questions, address deficiencies, and facilitate timely report completion.

Ensure reports meet established quality standards and are submitted to CMS within required deadlines.

Identify discrepancies, missing information, and opportunities for improvement throughout the review process.

Maintain a strong understanding of company processes, quality expectations, and applicable IDRE requirements.

Contribute to continuous process improvement initiatives designed to enhance quality, efficiency, and turnaround times.

Work collaboratively with the Operations team to support the company’s continued growth and operational success

Evaluates the Quality of the dispute rationale/ determination to ensure that all requirements have been met in compliance with internal and CMS guidelines.

Follow up with the arbiters for any pertinent and missing information

Assess whether the rationale is logical and the conclusions are based on sound assumptions

Maintain professionalism and courtesy when responding to emails and other communications, while ensuring all communications involving HIPAA and PHI are handled appropriately, securely, and in accordance with applicable privacy and confidentiality requirements.

Educations/Credentials:

An LPN, Associate’s or Bachelor’s degree is preferred; relevant professional experience in lieu of a degree may be considered.

Job Relevant Experience:

Business experience in a healthcare and/or insurance setting is preferred. :

• at Dane Street Government Services (North Haven Solutions) and enjoy a comprehensive benefits package designed to support your well-being and peace of mind.
• We offer a range of benefits including medical, dental, and vision coverage for you and your family.
• Additionally, we offer voluntary life insurance options for you, your spouse, and your children.
• We also offer other voluntary benefits which include hospital indemnity, critical illness, accident indemnity, and pet insurance plans.
• Employees receive basic life insurance, short-term disability, and long-term disability coverage at no cost.
• Our generous paid time off policy ensures you have time to relax and recharge, while our 401k plan with a company match helps you plan for your future.
• Apple equipment and a media stipend are provided for remote workspace.

ABOUT DANE STREET Goverment Services:

Dane Street’s Government Services Division provides specialized, compliant solutions that support federal and state program needs with efficiency, accuracy, and integrity. Through services such as Independent Dispute Resolution (IDR), North Haven partners with organizations to deliver clear outcomes that meet both operational and clinical standards. We serve as a trusted resource, bringing clarity, consistency, and confidence to complex review processes.