QUALITY REVIEW SPECIALIST

JOB PURPOSE:

Under the direction of the Manager of Quality Review, the Quality Review Specialist is responsible to review, triage, process, and/or investigate, as necessary, all service determination requests received. Will perform a quality review of all data submitted by the IDT teams and PACE Service Coordinators in Care Compass. The role will ensure that service determination requests (SDRs) are handled in a timely and efficient manner and in compliance with the relevant policies & procedures. The role will also perform a variety of duties involving entering, confirming, and updating patient service support documentation. This will include frequent communication with participants and collaboration with various teams within to effectively collect and process participant data.

JOB RESPONSIBILITIES:

• Reviews daily tasks and assign SDR cases for coordination with IDT and timely resolution.

• Provides all administrative-related information and routes accordingly for proper clinical review.

• Completes SDR assessments and coordination notes into Care Compass EMR database related to SDR process, approved services, delivered services, etc.

• Collaborates with Inter-disciplinary Team (IDT), CSDs, and Care Delivery Supervisors to ensure service determination requests (SDRs) are completed timely.

• Works closely with site-associated Care Delivery department to ensure data is entered correctly and timely.

• Reviews documentation completeness related to the rationale for all service determination requests (SDRs) IDT decisions.                                                           

• Outreaches participants, caregivers, representatives, IDT members and others to keep them informed about requests’ status or resolution.

• Keeps IDT members updated with SDR process status.

• Coordinates, documents & follows up with staff in different department's issues and/or requests resolutions.

• Completes assigned daily/weekly notification calls for all SDR decisions, including appeal rights information for denials and partial approvals.

• Completes validation calls to participants, caregivers or representatives to confirm that all approved services were received timely.

• Prepares detailed written responses to all participants/caregivers/representatives regarding the resolution of the service request.

• Responsible to complete, scan/upload into EMR all denial letters, including date-stamped mailing envelopes.

• Assists with follow-up and escalation of SDR step process as necessary.

• Provides general administrative support as needed.

• Monitors daily and weekly pending SDR case reports.

• Maintains departmental quality and productivity goals.

• Adheres to all applicable compliance requirements and the Code of Conduct.

• Only act within the scope of the individual’s authority to practice.

• Meet a standardized set of competencies for the specific position description established by the PACE organization before working independently.

• Acting member of the IDT.

Schedule: 8:30AM – 5:30PM

Weekly Hours: 40

QUALIFICATIONS:

Education: Associate's Degree in business, health care, or related field, or equivalent, with relevant customer service experience and excellent writing skills.

Experience:

• Minimum of one (1) year of experience working with a frail or elderly population or, if the individual has less than one (1) year of experience but meets all other requirements, must receive appropriate training from the PACE organization on working with a frail or elderly population upon hiring.

• Able to pass typing-test with at least 35 WPM.

• Excellent written and verbal communication skills (grammar, spelling, and punctuation).

• Ability to thrive in a fast-paced environment and meet assigned deadlines.

• Excellent organizational skills, accuracy, and attention to detail.

• Demonstrated ability to manage multiple projects and be flexible.

• Ability to operate both independently and collaboratively as required.

• Proficiency in Microsoft Office suite, including Word, Excel, and Outlook.

Additional Requirements:

• Be legally authorized (for example, currently licensed, registered, or certified if applicable) to practice in the State in which the healthcare professional will perform the function.

• Be medically cleared for communicable diseases and have all immunizations up-to-date before engaging in direct participant contact.