Utilization Review, Quality Assurance Specialist

🔥 0 minutes ago

🌽 Illinois – Remote

🌽 Illinois – Remote

💵 $45 - $52 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔧 QA Engineer (Quality Assurance)

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ExamWorks

WebsiteLinkedInAll Job Openings

5001 - 10000 employees

Founded 2008

⚕️ Healthcare Insurance

📋 Compliance

💸 Finance

Healthcare Insurance • Compliance • Finance

ExamWorks is a leading provider of independent medical examinations and peer reviews, specializing in services such as bill reviews, Medicare compliance, and document management. With a robust portfolio that includes agile development and enterprise platform solutions, ExamWorks ensures efficient workflow enhancements and compliance auditing across healthcare sectors. The company supports a network of physicians and offers customized services for the management of medical records and claims, prioritizing reliability for clients in various communities.

📋 Description

• Evaluate clinical information received, write and/or review various reports including, but not limited to: Medical Record Reviews, Medical Record Chronologies, Provider Bill Reviews, Coding Reviews, Hospital Bill Reviews, List of Missing Records, Medical Bill Apportionments, Mock Billing Invoice and Medical Summary Statements. • Perform quality assurance reviews of peer review reports, correspondences, addendums or supplemental reviews to ensure they meet company standards for content, clarity, evidence-based rationale, formatting, and professional presentation. • Ensure all client instructions and specifications have been followed, all questions have been answered, and all recommendations or determinations are supported by clear, concise, and evidence-based rationales. • Verify that each review includes appropriate clinical citations when applicable, and ensure all references cited are current and obtained from reputable medical journals and publications. • Identify inconsistencies within reports and contact the reviewer to obtain clarifications, modifications, or corrections needed. • Assist in the resolution of customer complaints and quality assurance issues as appropriate. • Ensure all federal ERISA and applicable state mandates are adhered to. • Provide ongoing feedback and recommendations to management regarding consultant performance, quality trends, and compliance with internal and client specific requirements. • Participate in the development and implementation of policies and procedures to improve efficiency and quality across operations. • Develop and lead formal and informal training sessions -individually or in groups -that promote high-quality utilization review practices and reinforce company standards. • Develop and document new or improved operational processes to support continuous improvement. • Promote effective and efficient utilization of company resources across all responsibilities. • Participate in or lead various continuing education and training activities related to clinical knowledge, industry standards, and company processes. • Perform other duties as assigned.

🎯 Requirements

• Must hold and maintain a Registered Nursing License. • Strong knowledge of group health/criteria sets/leadership/change management. • Must have strong understanding of medical terminology, anatomy and physiology, treatment protocols, medications and laboratory values. • Must be proficient in Microsoft Office Suite, Outlook, internet navigation and general office equipment. • Must have the ability to follow instructions and respond to upper managements’ directions accurately. • Ability to work independently, prioritize tasks, and manage time efficiently in a fast-paced environment. • Ability to demonstrate accuracy, thoroughness, and commitment to producing high quality work; actively monitor own performance and seek opportunities for improvement. • Ability to demonstrate flexibility and remain composed under pressure or in stressful conditions; adapts well to change and promotes a positive team environment. • Must be able to maintain confidentiality. • 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.

🏖️ Benefits

• medical • vision • dental • paid time off • 401k