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Quality Assurance Coordinator

72% Flex
Remote: 
Full Remote
Contract: 
Full time
Salary: 
60 - 70K yearly
Experience: 
Entry-level / graduate
Work from: 
Florida (USA)

Offer summary

Qualifications:

Associate or Bachelor's degree in Healthcare, Minimum 1 year experience in Utilization Review preferred, Medical experience such as LPN, RN, EMT preferred.

Key responsabilities:

  • Review treatment requests for correct guidelines and rationale
  • Audit decisions according to laws and guidelines
  • Identify trends, escalate issues, report and assist with QA audits
Ethos Risk Services logo
Ethos Risk Services Insurance SME https://ethosrisk.com/
501 - 1000 Employees
About Ethos Risk Services
Ethos Risk Services is a technology-backed, full-service claims management company. We bring clarity to a world of uncertainty through investigation and verification resources aimed at delivering optimal solutions to our clients. Services include surveillance, OSINT/digital investigations, SIU, and claims investigations. We also provide a full suite of medical management solutions that includes utilization management, field case management, IME, bill review, and Medicare services (MSP). Our coverage includes all 50 states and over 80 countries. We are SOC 2 Type 2 and HIPAA compliant. Our vision is to be the most tech-enabled, customer-centric claim management company that makes verification a matter of certainty. You want to be sure your claims are verified with all the facts. To do that you need all the facts, and delays increase costs. That’s why we’ve developed the technology and training to keep your claims on track for optimal outcomes. With our solutions you’ll save time and money with the peace of mind of having 100% surety. More Coverage. More Accountability. More Consistency.
See more Ethos Risk Services offers

Job description

Logo Jobgether

Your missions

About Us

Ethos Risk Services is a leading insurance claims investigation and medical management company committed to providing better data that translates into better decision-making for our clients. We are at the forefront of innovation in our space, and our success is driven by a dynamic team passionate about delivering exceptional services to our customers.

Job Summary

Our Ethos Risk team is seeking a full-time Quality Assurance Coordinator (remote), to provide independent review services and quality assurance auditing of determinations in accordance with all applicable laws and regulations. This role involves processing requests in our database, ensuring the security and confidentiality of health information, and adhering to established policies and procedures.

Key Responsibilities

Quality Assurance:

  • Review treatment requests for appropriate guideline application, consistency, and sufficient rationale.
  • Ensure decisions comply with client's evidence-based medicine (EBM) tolerances.
  • Escalate unresolved issues to the Director of Physician Services.
  • Monitor the Dashboard and prioritize cases with the earliest due times.
  • Identify trends and patterns for possible inclusion in the Quality Management Committee (QMC) process.
  • Track and report daily case reviews, including escalated or returned cases.
  • Report adverse trends or regulatory concerns to the Director of Physician Services.
  • Assist with external QA audits as needed.

Utilization Review

  • Conduct initial reviews to determine the appropriateness of Level 1 reviews.
  • Identify if additional medical information (RFI) is needed.
  • Determine if Administrative Denial (CA only) is appropriate based on clinical submissions.

Qualifications

Education:

  • Associate or Bachelor's of Science Degree or similar healthcare degree.

Experience

  • Medical experience preferred (LPN, LVN, RN, EMT, PT, OT).
  • Minimum 1 year of experience in Utilization Review.

Licenses/Certifications

  • Health occupation license preferred (does not need to be active).

Skills

  • Knowledge of anatomy and surgical procedures.
  • Strong critical thinking and goal-driven mindset.
  • Ability to break down complex issues and create clear written documentation.
  • Intermediate computer skills, including proficiency in MS Office Suite (Excel, PowerPoint, Word).

WORKING CONDITIONS

  • Office environment or home office with constant temperatures.
  • Prolonged periods of stationary positioning.
  • Frequent operation of computers and other office machinery.
  • Regular communication with clients, customers, and co-workers via telephone and in-person.

Location: Remote (US)

Type: Full-Time (Exempt)

Salary: $60,000 - $70,000

Ethos Risk Services is an equal opportunity employer that does not discriminate on the basis of religious creed, sex, national origin, race, veteran status, disability, age, marital status, color or sexual orientation or any other characteristic protected by law.

Salary: $60000 - $70000 per year

Job Posted by ApplicantPro

Required profile

Experience

Level of experience: Entry-level / graduate
Industry :
Insurance
Spoken language(s):
English
Check out the description to know which languages are mandatory.

Hard Skills

AnatomyMedical ProceduresClinical ExperienceMS Office

Soft Skills

  • Critical Thinking
  • Interpersonal Skills
Are you interested?

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