Remote Clinical QA Coordinator (RN) - Utilization Review

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

Job summary

AllMed Medical Management is seeking a Clinical Quality Assurance Coordinator, an RN who is detail-driven and passionate about quality. This 100% remote role supports Pacific Time Zone operations, with a Sunday-Thursday 8:00am-4:30pm PST schedule.

You will review care against evidence-based guidelines to ensure medical necessity and adherence to client agreements and federal/state mandates. You will collaborate with providers, document findings, and help maintain URAC and HIPAA compliance while

Qualifications

• Must hold and maintain an unencumbered Nursing license.
• UMR or IRO experience.
• Remote work experience.
• Strong knowledge of medical terminology, anatomy, physiology, medications, and lab values.
• Qualified typist with a minimum of 40 WPM.
• Knowledge of HIPAA regulations and compliance.

Responsibilities

• Perform quality utilization review using evidence-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.

Skills

RN license

Medical terminology

Anatomy & physiology

HIPAA compliance

Strong communication

Attention to detail

Independence

Time management

Confidentiality

Team collaboration

Education

Unencumbered Nursing License

Tools

Microsoft Word

Outlook

Excel

Internet

Job description

AllMed Medical Management is seeking a Clinical Quality Assurance Coordinator, an RN who is detail-driven and passionate about quality. This 100% remote role supports Pacific Time Zone operations, with a Sunday-Thursday 8:00am-4:30pm PST schedule.

You will review care against evidence-based guidelines to ensure medical necessity and adherence to client agreements and federal/state mandates. You will collaborate with providers, document findings, and help maintain URAC and HIPAA compliance while