Clinical Quality Assurance Coordinator (RN) (31512)

MES Solutions•Norwood, MA

74d•Remote

About The Position

MES is seeking a Clinical Quality Assurance Coordinator (RN) to join their growing team. This role involves reviewing medical records, extracting key information, and creating detailed narrative summaries. The position is 100% remote with flexible hours. The first 4-6 weeks involve training, with a preferred schedule of 12:00pm-8:30pm EST. MES emphasizes an employee-first culture with benefits and growth opportunities.

Requirements

High school diploma or equivalent required.
A minimum of two years clinical or related field experience; or equivalent combination of education and experience preferred.
Knowledge of the insurance industry, preferably claims management relative to one or more of the following categories: workers' compensation, no-fault, liability, or disability preferred.
LPN/LVN/RN may be required based on business needs.
Must have strong knowledge of medical terminology, anatomy and physiology, medications and laboratory values.
Must be a qualified typist with a minimum of 40 W.P.M.
Must have a full understanding of HIPAA regulations and compliance.
Must be able to operate a general computer, fax, copier, scanner, and telephone.
Must be knowledgeable of multiple software programs, including but not limited to Microsoft Word, Outlook, Excel, and the Internet.
Must demonstrate exceptional communication skills.
Ability to follow instructions and respond to upper managements’ directions accurately.
Must demonstrate accuracy and thoroughness.
Look for ways to improve and promote quality and monitors own work to ensure quality is met.
Must be able to work independently, prioritize work activities and use time efficiently.
Must be able to maintain confidentiality.
Must be able to demonstrate and promote a positive team -oriented environment.
Must be able to stay focused and concentrate under normal or heavy distractions.
Must be able to work well under pressure and or stressful conditions.
Must possess the ability to manage change, delays, or unexpected events appropriately.
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.
Ability to read, analyze and interpret common correspondence, medical records, and legal contracts and documents.
Ability to write clearly and informatively to all required audiences and edit own work for appropriate spelling and grammar.
Ability to respond appropriately and professionally to all inquiries or complaints from customers, physicians, regulatory agencies, and/or members of the business community.
Ability to effectively present information one-on-one or in small groups.

Nice To Haves

A minimum of two years clinical or related field experience; or equivalent combination of education and experience preferred.
Knowledge of the insurance industry, preferably claims management relative to one or more of the following categories: workers' compensation, no-fault, liability, or disability preferred.

Responsibilities

Performs quality assurance review of 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.
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 board 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 peer 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 adhered to the final report.
Identifies any inconsistencies within the report and contacts the Peer 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.