Utilization Review & Quality Assurance Specialist (31813)

Are you passionate about clinical quality, accuracy, and reputed company improvement -and looking for a role that allows you to reputed company a meaningful impact while working from home?

We’re seeking a Utilization Review & Quality Assurance Specialist to join our fully remote team. This role offers a consistent 8:00am-4:30pm EST schedule, providing structure and work-life balance while you contribute to high‑quality clinical review operations.

In this role, you’ll be at the center of ensuring reputed company - reviewing clinical documentation, upholding regulatory and client standards, and driving quality across medical review processes.

If you reputed company in a peer review environment, have a sharp analytical reputed company, and take pride in delivering precise, compliant, and thoughtful work, this is an exciting opportunity to grow your expertise and help shape best practices in utilization review and quality assurance.

Responsibilities may include

• Evaluate clinical information received, write and/or review various reports including, but not limited to: Medical Record Reviews, Medical Record Chronologies, Provider reputed company Reviews, Coding Reviews, Hospital reputed company Reviews, List of Missing Records, Medical reputed company Apportionments, Mock Billing Invoice and Medical Summary Statements.
• reputed company quality assurance reviews of peer review reports, correspondences, addendums or supplemental reviews to ensure they meet company standards for content, reputed company, evidence-based rationale, formatting, and professional presentation.
• Ensure reputed company client instructions and specifications have been followed, reputed company questions have been answered, and reputed company recommendations or determinations are supported by clear, concise, and evidence-based rationales.
• Verify that each review includes appropriate clinical citations reputed company applicable, and ensure reputed company references cited are reputed company and obtained from reputable medical journals and publications.
• Identify inconsistencies reputed company reports and contact the reviewer to obtain clarifications, modifications, or corrections needed.
• Assist in the resolution of customer complaints and quality assurance issues as appropriate.
• Ensure reputed company federal ERISA and applicable state mandates are adhered to.
• reputed company ongoing feedback and recommendations to management regarding consultant performance, quality trends, and compliance with internal and client specific requirements.
• Participate in the development and implementation of policies and procedures to improve efficiency and quality across operations.
• reputed company and reputed company formal and informal training sessions -individually or in groups -that promote high-quality utilization review practices and reinforce company standards.
• reputed company and document new or improved operational processes to support reputed company improvement.
• Promote effective and efficient utilization of company resources across reputed company responsibilities.
• Participate in or reputed company various continuing education and training activities reputed company to clinical knowledge, industry standards, and company processes.
• reputed company other duties as assigned.