Quality Assurance Coordinator (Clinical)

Overview

Quality Assurance Coordinator (Clinical) Jobs in United States at Sundayy

Title: Quality Assurance Coordinator (Clinical)

Company: Sundayy

Location: United States

About The Company

ExamWorks is a leading provider of innovative healthcare services dedicated to supporting property and casualty insurance carriers, law firms, third-party claim administrators, and government agencies. Our comprehensive suite of services includes independent medical examinations, peer reviews, bill reviews, Medicare compliance, case management, record retrieval, and document management. With a commitment to accuracy, integrity, and compliance, ExamWorks helps clients verify the validity of claims related to automotive, disability, liability, and workers' compensation insurance coverages. Our mission is to deliver reliable, timely, and high-quality healthcare solutions that facilitate informed decision-making and efficient claims processing.

About The Role

We are seeking a detail-oriented and experienced Clinical Quality Assurance Coordinator to join our team remotely. In this role, you will be responsible for reviewing peer review case reports to ensure they meet the highest standards of quality, accuracy, and regulatory compliance. Your primary focus will be to verify that reports adhere to client instructions, federal and state mandates, and industry guidelines. This position offers the flexibility of working from home while making a meaningful contribution to the integrity of our healthcare review processes. The ideal candidate will possess strong clinical knowledge, excellent attention to detail, and the ability to work independently in a fast-paced environment.

Qualifications

• High school diploma or equivalent required; minimum of two years clinical or related experience or equivalent education and experience.
• Experience in peer review, clinical documentation review, or medical necessity assessments.
• Familiarity with CMS guidelines, InterQual, Milliman/MCG, or payer policies.
• Prior employment with insurance carriers, TPAs, or managed care organizations preferred.
• Strong knowledge of medical terminology, anatomy, physiology, medications, and laboratory values.
• Proficiency in basic math skills, including calculating rates and percentages.
• Qualified typist with a minimum speed of 40 W.P.M.
• Proficient in operating computers, fax, copier, scanner, and telephone systems.
• Knowledge of software programs such as Microsoft Word, Outlook, Excel, and internet applications.
• Excellent command of English language, grammar, punctuation, and style.
• Ability to follow instructions accurately and respond effectively to management directives.
• Demonstrates accuracy, thoroughness, and a commitment to quality.
• Exceptional communication skills, including listening, conveying information clearly, and asking clarifying questions.
• Ability to work independently, prioritize tasks, and manage time efficiently.
• Ability to maintain confidentiality and handle sensitive information appropriately.

Responsibilities

• Perform quality assurance reviews of peer review reports, including case reports, correspondences, addendums, and supplemental reviews.
• Ensure all recommendations and determinations are supported by clear, evidence-based rationales.
• Verify adherence to client instructions, specifications, and regulatory guidelines.
• Confirm that reports include current, reputable medical citations and references, and that references are properly documented.
• Review the content, format, and professional appearance of reports to ensure they meet company standards.
• Ensure the appropriate board specialty has reviewed the case in compliance with client and legal requirements.
• Verify that peer reviewers have attested to factual accuracy and that no conflicts of interest exist.
• Ensure provider credentials and signatures are correctly documented on final reports.
• Identify inconsistencies within reports and liaise with peer reviewers for clarification or corrections.
• Assist in resolving client complaints and quality assurance issues as needed.
• Ensure compliance with federal ERISA and applicable state mandates at all times.
• Provide insights and recommendations to management regarding quality, compliance, and resource utilization.
• Participate in ongoing educational and training activities to stay current with industry standards.
• Perform additional duties as assigned to support team objectives and operational excellence.

Benefits

• Competitive medical, vision, and dental insurance plans.
• Paid time off and holidays.
• 401(k) retirement plan with company matching.
• Flexible work environment supporting remote work.
• Opportunities for professional development and training.
• Supportive team atmosphere focused on growth and collaboration.

Equal Opportunity

ExamWorks is an equal opportunity employer. We celebrate diversity and are committed to creating an inclusive environment for all employees. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, pregnancy, genetic information, disability, veteran status, or any other protected category under applicable federal, state, and local laws.