QUALITY REVIEW SPECIALIST (SDR)

C2Q Health Solutions•New York, NY

12d•$45,000 - $50,000

About The Position

Under the direction of the Manager of Quality Review, the Quality Review Specialist is responsible to review, triage, and process all service determination request received. The role will ensure that service determination requests (SDRs) are handled in a timely and efficient manner and in compliance with CMS regulatory requirements and company policies & procedures. The role will also perform a variety of duties involving entering, confirming, and updating participant service support documentation and communication with participants and various teams within the organization.

Requirements

Associates Degree in business, health care or related field, or equivalent with relevant customer service experience and excellent writing skills.
Able to pass typing-test with at least 40 WPM
Excellent written and verbal communication skills (grammar, spelling, and punctuation)
Ability to thrive in a fast-paced environment and meet assigned deadlines
Excellent organizational skills, accuracy and attention to detail
Demonstrated ability to manage multiple projects and be flexible.
Ability to operate both independently and collaboratively as required
Proficiency in Microsoft Office suite, including Word, Excel and Outlook
Individuals must be able to sustain certain physical requirements essential to the job. This includes, but is not limited to: Standing – Duration of up to 6 hours a day. Sitting/Stationary positions – Sedentary position in duration of up to 6-8 hours a day for consecutive hours/periods. Lifting/Push/Pull – Up to 50 pounds of equipment, baggage, supplies, and other items used in the scope of the job using OSHA guidelines, etc. Bending/Squatting – Have to be able to safely bend or squat to perform the essential functions under the scope of the job. Stairs/Steps/Walking/Climbing – Must be able to safely maneuver stairs, climb up/down, and walk to access work areas. Agility/Fine Motor Skills - Must demonstrate agility and fine motor skills to operate and activate equipment, devices, instruments, and tools to complete essential job functions (ie. typing, use of supplies, equipment, etc.) Sight/Visual Requirements – Must be able to visually read documentation, papers, orders, signs, etc., and type/write documentation, etc. with accuracy. Audio Hearing and Motor Skills (language) Requirements – Must be able to listen attentively and document information from patients, community members, co-workers, clients, providers, etc., and intake information through audio processing with accuracy. In addition, they must be able to speak comfortably and clearly with language motor skills for customers to understand the individual. Cognitive Ability – Must be able to demonstrate good decision-making, reasonableness, cognitive ability, rational processing, and analysis to satisfy essential functions of the job.

Responsibilities

Collaborates with Inter-disciplinary Team (IDT), CSDs, and Care Delivery Supervisors to ensure service determination requests (SDRs) are completed timely.
Works closely with site associated Care Delivery department to ensure data is entered correctly and timely.
Reviews daily tasks and assigned SDR cases for coordination with IDT and timely resolution.
Provides all administrative related information and routes accordingly for proper IDT review.
Completes SDR assessments and coordination notes into Care Compass (EMR) related to SDR process, approved/denied services, and effectuated items or services.
Reviews documentation completeness related to rationale for all service determination requests (SDRs) IDT decisions.
Outreaches participants, caregivers, representatives, IDT members and others to keep them informed about requests’ status or resolution.
Keeps IDT members updated with SDR process status.
Coordinates, documents & follows up with staff in different departments issues and/or requests resolutions.
Completes assigned daily/weekly notification calls for all SDR decisions, including appeal rights information for denials and partial approvals.
Completes validation calls to participants, caregivers or representatives to confirm that all approved services were received timely.
Prepares detailed written responses to all participants/caregivers/representatives regarding the resolution of the service request.
Responsible to complete, scan/upload into EMR all letters, including date stamped mailing envelope when necessary.
Assists with follow-up and escalation of SDR step process as necessary.
Provides general administrative support as needed.
Monitors daily and weekly pending SDR case reports.
Maintains departmental quality and productivity goals.
Adheres to all applicable compliance requirements and the Code of Conduct.