Clinical Quality Assurance Coordinator (32945)

Join Our Team as a Clinical Quality Assurance Coordinator!

Are you an RN (Registered Nurse) who is detail-driven, passionate about quality, and excited to make a meaningful impact in healthcare? AllMed is looking for a motivated Clinical Quality Assurance Coordinator to help us ensure excellence in every review we deliver.

This is a 100% remote opportunity that offers the flexibility of working from home. The role primarily supports Pacific Time Zone operations, with schedules falling within business hours of 5:00am to 5:30pm PST. Candidates should be comfortable working a set schedule within that timeframe, and occasional weekend coverage may be required based on business needs.

In this role, you’ll play a critical part in delivering high-quality utilization review services. You’ll review and approve care based on evidence-based guidelines, ensuring medical necessity and appropriateness. Your work will uphold the highest standards of accuracy, integrity, and compliance with client agreements, regulatory requirements, and federal/state mandates.

Responsibilities may include:

• Perform quality utilization review through the use of acquired knowledge and application of evidenced based guidelines for peer review reports, correspondences, addendums and/or supplemental reviews.
• Work directly with providers to identify level, intensity and duration of care.
• Document findings, continue to evaluate medical necessity for frequency, intensity and length of required care.
• Assure that the consistency and quality of reviews meets or exceeds industry standards.
• Work to ensure quality reviews are completed within the required client, federal and state or URAC mandated turnaround times.
• Maintain and apply knowledge of URAC and other state and federal regulatory requirements.
• Maintain accurate record of Utilization Reviews within the appropriate database.
• Direct Customer Service Representatives to ensure timely delivery of determination letters.
• Assist in resolution of client complaints and/or quality assurance issues as needed.
• Ensure all quality assurance standards and federal ERISA, URAC, and/or other state guidelines are adhered to at all times.
• Provide insight and direction to management on any compliance concerns regarding products, company policies and procedures and/or client specifications.
• Participate in company meetings, training activities and continuing education requirements.
• Perform all other duties as assigned.

If you thrive in a collaborative environment and love contributing to high-quality clinical outcomes, we’d love to meet you!