Utilization Review, Quality Assurance Specialist

Responsibilities

• Evaluate clinical information received, write and/or review various reports including, but not limited to: Medical Record Reviews, Medical Record Chronologies, Provider Bill Reviews, Coding Reviews, Hospital Bill Reviews, List of Missing Records, Medical Bill Apportionments, Mock Billing Invoice and Medical Summary Statements.
• Perform quality assurance reviews of peer review reports, correspondences, addendums or supplemental reviews to ensure they meet company standards for content, clarity, evidence-based rationale, formatting, and professional presentation.
• Ensure all client instructions and specifications have been followed, all questions have been answered, and all recommendations or determinations are supported by clear, concise, and evidence-based rationales.
• Verify that each review includes appropriate clinical citations when applicable, and ensure all references cited are current and obtained from reputable medical journals and publications.
• Identify inconsistencies within reports and contact the reviewer to obtain clarifications, modifications, or corrections needed.
• Assist in the resolution of customer complaints and quality assurance issues as appropriate.
• Ensure all federal ERISA and applicable state mandates are adhered to.
• Provide ongoing feedback and recommendations to management regarding consultant performance, quality trends, and compliance with internal and client specific requirements.
• Participate in the development and implementation of policies and procedures to improve efficiency and quality across operations.
• Develop and lead formal and informal training sessions – individually or in groups – that promote high-quality utilization review practices and reinforce company standards.
• Develop and document new or improved operational processes to support continuous improvement.
• Promote effective and efficient utilization of company resources across all responsibilities.
• Participate in or lead various continuing education and training activities related to clinical knowledge, industry standards, and company processes.
• Perform other duties as assigned.

Requirements

• Must hold and maintain a Registered Nursing License.
• Strong knowledge of group health/criteria sets/leadership/change management.
• Must have strong understanding of medical terminology, anatomy and physiology, treatment protocols, medications and laboratory values.
• Must be proficient in Microsoft Office Suite, Outlook, internet navigation and general office equipment.
• Must have the ability to follow instructions and respond to upper managements’ directions accurately.
• Ability to work independently, prioritize tasks, and manage time efficiently in a fast-paced environment.
• Ability to demonstrate accuracy, thoroughness, and commitment to producing high quality work; actively monitor own performance and seek opportunities for improvement.
• Ability to demonstrate flexibility and remain composed under pressure or in stressful conditions; adapts well to change and promotes a positive team environment.
• Must be able to maintain confidentiality.
• Ability to follow all company policies and procedures in effect at time of hire and as they may change or be added from time to time.
• Core Competencies

Demonstrates expertise in clinical evaluation and report writing, ensuring adherence to federal ERISA mandates and company standards.

Proficient in developing training sessions and operational processes to enhance quality and efficiency in utilization review practices.

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