Quality Review Manager (31926)

EXAMWORKS COMPLIANCE SOLUTIONS LLC•Lawrenceville, GA

1d•Hybrid

About The Position

The Quality Review Manager is responsible to work autonomously to complete full audit, review and approval of the following, but not limited to: Life Care Plans, Medical Cost Projections, Medicare Set-Aside Allocations, Legal Nurse Reviews, Complex Nurse Reviews, Bill Reviews, initial and progress reports for medical or vocational case management files and other reports as needed within the scope of nursing practice and certifications. The Quality Review is responsible to monitor the overall quality of all the work products and effectively communicate with the planner team to include development of alternative treatment plans or recommendations for moving the file toward maximum resolution at the highest level of quality and timeliness possible.

Requirements

Associates degree required.
A minimum of three years worker’s compensation experience.
Active unrestricted Registered Nursing license.
Must have minimum active certification in Medicare Set-Asides.
Must have knowledge of the disability and workers' compensation industry including rules and regulations and an understanding of clinical procedures and all processes involved in the delivery of quality health care to an injured worker.
Must be able to adequately operate a general computer and telephone.
Must have strong knowledge of multiple software programs, including but not limited to Microsoft Word, Outlook, Excel, and the Internet.
Must have knowledge of current laws and regulations that govern delivery of rehabilitation services.
Must have knowledge of human behavior and performance.
Ability to demonstrate strong customer service knowledge including needs assessment, meeting quality standards for services and evaluation of customer satisfaction.
Must demonstrate exceptional communication skills by conveying necessary information accurately, listening effectively and asking questions where clarification is needed.
Must be able to work independently, prioritize work activities and use time efficiently.
Ability to concentrate and multitask in a fast-paced work environment.
Must demonstrate accuracy and thoroughness and look for ways to improve and promote quality and monitor own work to ensure quality is met.
Must be able to maintain confidentiality.
Must be able to demonstrate and promote a positive team -oriented environment.
Must be able to work well under pressure and/or stressful conditions and have 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 itemized billing statements, 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, regulatory agencies, upper management, and/or members of the business community.
Ability to effectively present information one-on-one, in small groups, and/or to clients or vendors of the company.

Nice To Haves

Bachelor’s degree in health-related field preferred.
Three to five years Medicare Compliance preferred.
Additional certification in Life Care Planning and/or Legal Nurse Consulting preferred.

Responsibilities

Collaborates with Planner team through education and recommendations on past/future treatment to optimize outcomes with client interfacing
Work autonomously and collaborate with the Clinical Services Team and all company personnel as needed and communicate with the accounts and attorneys as needed.
Maintain through audit a quality work product evidenced by acceptable quality scores and standards.
Participate in company orientation, management meetings and/or conference calls as required.
Ensure all federal Centers for Medicare and Medicaid Services (CMS) requirements and/or state mandates are adhered to at all times.
Provide insight and direction to management on report quality and compliance with all company policies and procedures, client specifications, URAC and CMS guidelines.
Promote effective and efficient utilization of company resources.
Participate in various educational and or training activities as required.
Perform other duties as assigned.
Carrying out all responsibilities in accordance with the company’s standards, policies, and all applicable employment laws.
Managing and monitoring workflow and providing support, training, and techniques to assist staff in achieving department daily/weekly/monthly goals and standards.
Encouraging positive morale, maintaining harmony among staff, and resolving grievances when necessary.
Overseeing the completion and approval of employee timecards and coordinating overtime needs with management and staff as needed.
Actively participating in the department’s staffing requirements including hiring, onboarding, and separating of employees.
Creating and implementing plan to meet department’s goals and metrics based on workload and client needs.
Communicating change effectively and supporting those affected by change.
Managing insubordinate staff when warranted and initiating coaching or corrective actions as required and/or directed by upper management.
Evaluating staff needs and performance, providing periodic feedback to staff and reporting any performance concerns and/or recommendations growth opportunities to management.
Actively participating and successfully conducting annual performance evaluations.