• Quality Review Specialist

    Requisition ID
    2018-3753
    # of Openings
    1
    Category
    Operations
    Location
    US-Anytown
  • Overview

    The Quality Review Specialist is responsible for reviewing submitted reports to ensure the quality expectations of our customers and company-specific guidelines are met.  This position will work closely with the assigned Case Manager to advise and ensure the necessary report revisions are made.  The Quality Review Specialist will aid in identifying trends and assist with training as well as assist with internal and external audits to measure the quality of our Case Management services.

     

    This is a part-time position, less than 15 hours per week. 

    Responsibilities

    ESSENTIAL DUTIES AND RESPONSIBILITIES TO PERFORM THIS JOB SUCCESSFULLY INCLUDE, BUT ARE NOT LIMITED TO THE FOLLOWING:

    • Review reports in Caseworks against quality and compliance guidelines to ensure the report meets the minimum requirements.
    • Effectively communicate with case manger’s regarding any revision requirements or quality concerns.
    • Utilize the QA scoring tool to measure compliance with meeting quality criteria
    • Assist with internal and external customer audits to measure the quality of our case management services against the service instructions.
    • Participate in company orientations, management meetings and/or conference calls as required.
    • Aid in identifying industry trends and participate in case manager training.
    • Proficient in working in customer’s claims systems to enter data or complete required quality staffings or audits
    • Provides insight and direction to management on report quality and compliance with all company-specific policies and procedures, client specifications and URAC guidelines.
    • Promote effective and efficient utilization of company resources.
    • Participate in various educational and or training activities as required.
    • Perform other duties as assigned. 

    Qualifications

    EDUCATION AND/OR EXPERIENCE

    • Associates Degree required, Bachelor’s Degree preferred. Must be a graduate of a national accredited nursing program.
    • Minimum of 5 years workers’ compensation rehabilitation and/or case management experience required.

    QUALIFICATIONS 

    • Active and unrestricted Nursing license required.
    • A minimum of 5 years of workers’ compensation rehabilitation and/or case management experience required.
    • Knowledge of the disability and workers' compensation industry including rules and regulations and an understanding of clinical procedures and all processes involved in the delivery of quality health care to an injured worker.
    • Must be able to adequately operate a general computer, fax, copier, scanner, and telephone.
    • Must have strong knowledge of multiple software programs, including but not limited to Microsoft Word, Outlook, Outlook Web Access, Excel, and the Internet.
    • Knowledge of current laws and regulations that govern delivery of rehabilitation services.
    • Knowledge of human behavior and performance.
    • Ability to demonstrate strong customer service knowledge including needs assessment, meeting quality standards for services and evaluation of customer satisfaction.
    • Must demonstrate exceptional communication skills by conveying necessary information accurately, listening effectively and asking questions where clarification is needed.
    • Must be able to work independently, prioritize work activities and use time efficiently.
    • Ability to concentrate and multitask in a fast paced work environment.
    • Demonstrates accuracy and thoroughness. Looks for ways to improve and promote quality and monitors own work to ensure quality is met.
    • Must be able to maintain confidentiality.
    • Must be able to demonstrate and promote a positive team-oriented environment.
    • Must be able to work well under pressure and/or stressful conditions.
    • Must possess the ability to manage change, delays, or unexpected events appropriately.
    • Must possess excellent skills in English usage, grammar, punctuation and style.
    • Demonstrates reliability and abides by the company attendance policy.
    • Must maintain a professional and clean appearance at all times consistent with company standards.
    • Ability to read, analyze and interpret common to complex correspondence, medical records, various reporting records, legal contracts and/or related case documents.
    • Ability to write clearly and informatively to all required audiences and edit own work for appropriate spelling and grammar.
    • Ability to respond appropriately and professionally to all inquiries or complaints from clients, physicians, upper management, regulatory agencies, and/or members of the business community.
    • Ability to effectively present information one-on-one, in small groups, and/or clients or vendors of the company.

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