Quality Assurance Coordinator (29685)

SUMMARY

The Quality Assurance Coordinator is responsible to ensure reports are completed at the highest level of quality and integrity and in full compliance with client contractual agreement, regulatory agency standards and/or federal and state mandates. This position is required to handle quality assurance questions and provide overall support to the Quality Assurance Department.

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.

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.

MINIMUM REQUIRED QUALIFICATIONS

Education and/or Experience  

High school diploma or equivalent required. Two years IME or medical experience preferred. Knowledge of the insurance industry preferably claims management relative to one or more of the following categories: workers' compensation, no-fault, liability, and/or disability preferred.

Certificates, Licenses, Registrations  

No specific requirements.

ESSENTIAL COMPETENCIES

QUALIFICATIONS 

• 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 preferred.
• 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