QA Specialist - clerical

Job Description

Job Description

The Quality Assurance Specialist is responsible for ensuring processes, adherence to compliance processes and protocols, coordination of activities so that customer service and satisfaction is ensured and that regulatory compliance requirements are met with regard to the final product / report.

Key Responsibilities

• Performs quality assurance review of IME / peer review reports, correspondences, addendums or supplemental reviews.
• Ensures clear, concise, evidence-based rationales have been provided in support of all recommendations and / or determinations.
• Ensures that all client instructions and specifications have been followed and that all questions have been addressed.
• Where required ensures 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.
• Ensures the content, format, and professional appearance of the reports are of the highest quality and in compliance with company standards.
• Ensure that the appropriate medical specialty has reviewed the case in compliance with client specifications and / or state mandates and is documented accurately on the case report.
• Verifies that the reviewer has attested to only the fact(s) and that no evidence of reviewer conflict of interest exists.
• Ensures the provider credentials and signature are on the final report.
• Identifies any inconsistencies within the report and contacts the reviewer to obtain clarification, modification or correction as needed.
• Assists in resolution of customer complaints and quality assurance issues as needed.
• Ensures all federal ERISA and / or state mandates are adhered to at all times.
• Provides 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.
• Perform other duties as assigned.
• Has an excellent command of grammar and medical terminology
• Meets specific department metrics
• Operates company software and equipment
• Enters data by inputting alphabetic and numeric information into system via keyboard
• Maintains confidentiality and discretion as a general rule
• Works effectively as a team contributor on all assignments
• Interacts professionally with other employees as well as clients
• Has a clear and concise understanding, and adheres to, guidelines as they relate to HIPAA, Conflict of Interest, and Ethics
• Understands current URAC standards as appropriate to job functions

Key Competencies / Skills / Abilities

Background & Experience

HS Diploma or equivalent

Proficiency with MS Office Suite and Excel

Relevant industry related experience (IME / Peer Reviews, Legal, Claims experience)LPN / RN Degree a plus - Where applicable, employee must notify the Quality Manager immediately of any changes in professional active license status for any state license is being utilized for current position or current certifications status

Physical Requirements