Quality Assurance Coordinator

• St. Petersburg, FL, USA
• 60000-70000 per year
• Salary
• Full Time

ABOUT US

Ethos Risk Services is a leading insurance claims investigation and medical management company committed to providing better data that translates into better decision-making for our clients.

We are at the forefront of innovation in our space, and our success is driven by a dynamic team passionate about delivering exceptional services to our customers.

JOB SUMMARY

Our Ethos Risk team is seeking a full-time Quality Assurance Coordinator (remote) , to provide independent review services and quality assurance auditing of determinations in accordance with all applicable laws and regulations.

This role involves processing requests in our database, ensuring the security and confidentiality of health information, and adhering to established policies and procedures.

KEY RESPONSIBILITIES :

Quality Assurance :

• Review treatment requests for appropriate guideline application, consistency, and sufficient rationale.
• Ensure decisions comply with client's evidence-based medicine (EBM) tolerances.
• Escalate unresolved issues to the Director of Physician Services.
• Monitor the Dashboard and prioritize cases with the earliest due times.
• Identify trends and patterns for possible inclusion in the Quality Management Committee (QMC) process.
• Track and report daily case reviews, including escalated or returned cases.
• Report adverse trends or regulatory concerns to the Director of Physician Services.
• Assist with external QA audits as needed.

Utilization Review :

• Conduct initial reviews to determine the appropriateness of Level 1 reviews.
• Identify if additional medical information (RFI) is needed.
• Determine if Administrative Denial (CA only) is appropriate based on clinical submissions.

QUALIFICATIONS

Education :

Associate or Bachelor's of Science Degree or similar healthcare degree.

Experience :

• Medical experience preferred (LPN, LVN, RN, EMT, PT, OT).

Licenses / Certifications :

Health occupation license preferred (does not need to be active).

Skills :

• Knowledge of anatomy and surgical procedures.
• Strong critical thinking and goal-driven mindset.
• Ability to break down complex issues and create clear written documentation.
• Intermediate computer skills, including proficiency in MS Office Suite (Excel, PowerPoint, Word).

WORKING CONDITIONS

• Office environment or home office with constant temperatures.
• Prolonged periods of stationary positioning.
• Frequent operation of computers and other office machinery.
• Regular communication with clients, customers, and co-workers via telephone and in-person.

Location : Remote (US)

Type : Full-Time (Exempt)

Salary : $60,000 - $70,000

Ethos Risk Services is an equal opportunity employer that does not discriminate on the basis of religious creed, sex, national origin, race, veteran status, disability, age, marital status, color or sexual orientation or any other characteristic protected by law.

Last updated : 2024-06-19