Quality Assurance Coordinator

Under the direction of the Director of Utilization Management and Customer Service, this position is responsible to audit UR cases and authorizations on a daily basis to ensure quality, accuracy, compliance with Health Plan and regulatory requirements. The Quality Assurance Coordinator will interact with other departments, clinic personnel, and outside providers in a professional and friendly manner, to create and maintain a positive relationship with our internal and external customers.

• Review coding of requested authorization services to ensure accuracy and quality.
• Auditing final determinations of case and authorizations to ensure decision meets authorization standards. Including accurate logging of determinations in system are appropriately captured by staff.
• Monitoring daily aging reports to ensure compliance with timeliness regulations.
• Tracking and documenting of all identified errors by UR staff members and reporting errors to management bi-weekly to ensure training to staff in needed areas.
• Assist with training, education and orientation of UR staff on new and existing processes and procedures.
• Provide feedback to appropriate staff members when errors are identified.
• Assist UR with special projects as needed.
• Random quarterly interrater file review audits on UR staff following Medicare 8/30 auditing rules in compliance with UM compliance regulations.
• Responsible for auditing, reviewing and/or processing of UR reporting which may include potential errors, member eligibility, Corporate reports, and staff productivity.
• Auditing compliance of authorization notifications to determine compliance with policy and procedure.
• Audit of staff compliance of researching sanctions against Out of Network provider/facility licenses utilizing the Office of Inspector General (OIG), CMS Opt-Out, System of Award Management (SAM) websites and the Medicare Preclusion list as required by regulations. Results of each OON provider/facilities researched must be filed and documented in accordance with regulations.
• Communicate with internal and external staff, members, providers and Health Plans regarding nature of UR cases and referrals, status updates including prompt response to inquiries.
• Demonstrate a complete understanding of established UR/ HPN, Health Plan and regulatory policies and procedures in regard to cases, authorizations, appeals & grievances.
• Auditing of NextGen filed documents by UR staff.
• General understanding of UR databases utilized.
• Fluent understanding of authorization processing responsibilities and procedures for each role within UR, including the capability to perform each non-clinical UR role with accuracy and fluency.
• Assist with audit preparation, review and compiling of all requested audit files/documents.
• Timely submission of all auditing documents and evidence to appropriate Health Plans auditors by specified deadlines.
• Maintain and monitor audit calendar to include the following: Audit dates, Corrective Action Plan (CAP) responses, and Health Plan trainings.
• Keep UR Management team abreast of all audit deadlines.
• Organization and maintenance of all UR Health Plan and Line of Business (LOB) specific written letter templates, to include Post Stabilization, NOMNC, DENC, DND, Refusal to Transfer, Aberrant letters and multi-language health plan inserts.
• Maintain organization of assigned duties and prioritize based on urgency. Inform management if there is a potential delay in completing assignments.
• Adaptable to regulation and necessary departmental procedure changes that affect UR case and authorization processes.
• Compliance with HIPAA regulations and maintenance of patient confidentiality.
• Cultural and Linguistics training required annually.
• Other duties as assigned.

8.1 High school diploma or GED certification, required.

8.2 Two years recent Managed Care experience, required.

8.3 Two years' Utilization Review or Utilization Management experience, required.

8.4 Typing certification of 40 wpm, required.

8.5 Excellent written and oral communication skills.

8.6 Detailed knowledge of CPT, HCPCs, and ICD-10 coding.

8.7 Familiar with medical terminology.

8.8 Proficient in Microsoft Word, Excel and UM systems utilized, preferred.

8.9 Must have ability to multitask, problem solve and make independent decisions in a fast pace work environment.

The pay range for this position at commencement of employment is expected to be between $26.09 and $30.69 However, base pay offered may vary depending on multiple individualized factors, including market location, job-related knowledge, skills, and experience.

If hired, employee will be in an “at-will position” and the Company reserves the right to modify base salary (as well as any other discretionary payment or compensation program) at any time, including for reasons related to individual performance, Company or individual department/team performance, and market factors.