Remote RN: Clinical Quality & Utilization Review Specialist

AllMed Medical Management; United States; Remote; USD 70,000 - 100,000; Full time

Benefits offered by this job

Medical, vision, dental

401(k)

Paid time off

Job summary

AllMed Medical Management is seeking a Clinical Quality Assurance Coordinator. This 100% remote role supports Pacific Time Zone operations, with a Sunday-Thursday 8:00am-4:30pm PST schedule.

The position focuses on high-quality utilization reviews and adherence to evidence-based guidelines, HIPAA, URAC, and client requirements. The ideal candidate is an RN with UMR/IRO experience, strong medical terminology knowledge, and the ability to work independently while maintaining confidentiality in a

Qualifications

• Must hold and maintain an unencumbered Nursing license.
• UMR or IRO experience.
• Remote work experience.
• Strong knowledge of medical terminology, anatomy and physiology, medications and laboratory values.
• Must be a qualified typist with a minimum of 40 WPM.
• Must have HIPAA regulations and compliance knowledge.
• Proficient with Microsoft Word, Outlook and Excel.
• Excellent communication and attention to detail.
• Ability to work independently and manage time effectively.
• Maintain confidentiality and adapt to changes.

Responsibilities

• Perform quality utilization review using evidence-based guidelines for peer reviews and related documents.
• Work with providers to identify level, intensity and duration of care.
• Document findings and evaluate medical necessity for frequency, intensity and length of care.
• Ensure reviews meet client, federal and URAC guidelines and turnaround times.
• Maintain accurate records of Utilization Reviews.
• Direct Customer Service Representatives to ensure timely delivery of determination letters.
• Assist in resolution of client complaints and quality issues.
• Adhere to ERISA, URAC and state guidelines.
• Provide insight to management on compliance concerns.
• Participate in meetings and continuing education requirements.
• Perform all other duties as assigned.

Skills

RN license

UMR/IRO

Remote work

HIPAA compliance

Medical terminology

40 WPM

Strong communication

Education

Nursing license

Tools

Microsoft Word

Outlook

Excel

Internet

Job description

AllMed Medical Management is seeking a Clinical Quality Assurance Coordinator. This 100% remote role supports Pacific Time Zone operations, with a Sunday-Thursday 8:00am-4:30pm PST schedule.

The position focuses on high-quality utilization reviews and adherence to evidence-based guidelines, HIPAA, URAC, and client requirements. The ideal candidate is an RN with UMR/IRO experience, strong medical terminology knowledge, and the ability to work independently while maintaining confidentiality in a