Remote Clinical QA Coordinator

ExamWorks, Inc.; Southfield (MI); Remote; USD 60,000 - 85,000; Full time

Benefits offered by this job

Remote work

Competitive benefits

Job summary

ExamWorks, Inc. is seeking a Clinical Quality Assurance Coordinator to review peer reports for quality, accuracy and regulatory compliance.

This 100% remote role targets nurses with peer review or medical necessity assessment experience, CMS guideline familiarity, and prior insurer or managed care exposure. Responsibilities include QA reviews, evidence-based rationales, client instruction adherence, and maintaining high report quality with proper citations.

Qualifications

• High school diploma or equivalent required with a minimum 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.

Responsibilities

• 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.

Skills

Peer review experience

Clinical terminology knowledge

Strong English communication

Typing speed 40 WPM

Independent worker

Education

High school diploma or equivalent

Tools

Microsoft Word

Outlook

Excel

Job description

ExamWorks, Inc. is seeking a Clinical Quality Assurance Coordinator to review peer reports for quality, accuracy and regulatory compliance.

This 100% remote role targets nurses with peer review or medical necessity assessment experience, CMS guideline familiarity, and prior insurer or managed care exposure. Responsibilities include QA reviews, evidence-based rationales, client instruction adherence, and maintaining high report quality with proper citations.