Quality Assurance Specialist (Medical Program)

Responsibilities:

Carry out quality assurance oversight activities defined in the Client Managed Care National Best Practices and Quality Assurance Standards
Conduct regular and systematic review of Managed Care internal and external claim files with focus towards validation of consistent evaluation of evidence-based medicine, comprehensive assessments, proactive medical and disability management.
Reviews to focus on completion of activities and case management goals in timely manner, have appropriate follow up, appointments are made within recommended frequency, and ensure there are no gaps in service and medical care coordination.
Analysis of Quality Assurance reporting metrics to identify strengths, trending, and provide recommendations which can support and tie into education training development needs for the overall programs.
Measure and identify staffing competency levels from quality assurance reviews.
Work with leadership and staff to calibrate quality standards across all offices.
Qualifications:
Unrestricted active RN license
Bachelor's degree in nursing (BSN)
Certification in case management, rehabilitation nursing or related specialty preferred.
Quality Assurance program designations such as Health Care Quality and Management certification (HCQM) highly preferred.
Minimum two (2) years direct clinical care required but not limited to trauma, emergency, intensive care, orthopedic, neurology.
Written and verbal fluency in English is required
Combination of two (2) years in either utilization review programs for Group Health or Worker's Compensation or experience in a quality assurance role required
Understanding and prior experience with URAC accreditation for utilization review is preferred.