Quality Assurance Coordinator

MCMC is seeking a detaildriven Quality Assurance Coordinator to join our team in a fully remote capacity. In this role, you will play a key part in supporting the integrity of our investigative processes by ensuring accuracy, compliance, and quality across fraud, waste, and abuse (FWA) reviews.

You should have strong working knowledge of FWA detection methodologies, along with an advanced understanding of CPT, HCPCS, ICD10, and relevant billing and payment policies.

This position is 100% remote with a schedule of 9:00am-5:30pm EST.

Responsibilities may include:

• Perform quality assurance review of reports, correspondences, addendums or supplemental reviews.
• Ensure clear, concise, evidence-based rationales have been provided in support of all recommendations and/or determinations.
• Ensure that all client instructions and specifications have been followed and that all questions have been addressed.
• Ensure each review is supported by clinical citations and references when applicable and verifies that all references cited are current and obtained from reputable medical journals and/or publications.
• Ensure the content, format, and professional appearance of the reports are of the highest quality and in compliance with company standards.
• Ensure that the appropriate board specialty has reviewed the case in compliance with client specifications and/or state mandates and is documented accurately on the case report.
• Verify that the peer reviewer has attested to only the facts and that no evidence of reviewer conflict of interest exists.
• Ensure the provider credentials and signature are adhered to the final report.
• Identify any inconsistencies within the report and contact the Provider to obtain clarification, modification or correction as needed.
• Assist in resolution of customer complaints and quality assurance issues as needed.
• Ensure all federal ERISA and/or state mandates are adhered to at all times.
• Provide insight and direction to management on consultant quality, availability and compliance with all company policies and procedures and client specifications.
• Promote effective and efficient utilization of company resources.
• Participate in various educational and or training activities as required.
• Perform other duties as assigned.

If you excel in investigative detail, thrive in a qualityfocused environment, and are ready for a fully remote opportunity, we'd love to meet you.

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  Bachelor's degree or equivalent experience (3-5 years investigative experience in Group Health SIU fraud, waste and abuse (FWA) investigations or medical claims environment )

  
  
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  Strong knowledge of fraud, waste, and abuse (FWA) detection and investigative practices

  
  
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  Advanced understanding of CPT, HCPCS, ICD-10, and billing/payment policies

  
  
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  Must have strong knowledge of medical terminology, anatomy and physiology, medications and laboratory values.

  
  
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  Knowledge and understanding of complex clinical issues

  
  
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  Knowledge of Health Plan policies and procedures.

  
  
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  Strong analytical and research skills

  
  
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  Proficient in researching information and identifying information resources

  
  
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  Must be knowledgeable of multiple software programs, including but not limited to Microsoft Word, Outlook, Excel, and the Internet.

  
  
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  Must possess excellent skills in English usage, grammar, punctuation and style.

  
  
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  Must be able to work independently, prioritize work activities and use time efficiently.

  
  
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  Ability to follow instructions and respond to upper managements' directions accurately.

  
  
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  Demonstrates accuracy and thoroughness. Looks for ways to improve and promote quality and monitors own work to ensure quality is met.

  
  
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  Must demonstrate exceptional communication skills by conveying necessary information accurately, listening effectively and asking questions where clarification is needed.

  
  
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  Must be able to maintain confidentiality.

  
  
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  Must be able to demonstrate and promote a positive team -oriented environment.

  
  
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  Must be able to stay focused and concentrate under normal or heavy distractions.

  
  
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  Must be able to work well under pressure and or stressful conditions.

  
  
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  Must possess the ability to manage change, delays, or unexpected events appropriately.

  
  
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  Demonstrates reliability and abides by the company attendance policy.

  
  

MCMC completes over 100,000 reviews each year for more than 400 clients, including almost all of the nation's largest Health Plans, PBMs, Disability Carriers, TPAs, UR companies, Self-Insured Employers, Taft-Hartley Plans and Government Organizations.

Equal Opportunity Employer. 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, status as a protected veteran, or any other protected category under applicable federal, state, and local laws.

MCMC offers a fast-paced team atmosphere with competitive benefits (medical, vision, dental), paid time off, and 401k.