Group Health Oncology Utilization Review Nurse - Clinical Review Preparation

JOB SUMMARY

The QA Specialist plays an integral role in the review process as they are responsible for communicating with the customer, reviewer, and management to ensure a completed report is delivered by the customer requested due date.

The QA Specialist is responsible for the timely completion and overall completeness of a reviewer report. Completeness is determined by customer requirements, company best practices, and clinical accuracy. In addition, the QA Specialist participates in improving DS processes and works with the Manager to ensure high efficiencies are achieved.

MAJOR DUTIES & RESPONSIBILITIES

Client Interaction

• Provides regular report status updates to the client.
• Evaluates the Quality of physician’s report and determines if the report will meet all client and jurisdictional standards; the QA Specialist is also responsible for ensuring that the clinical rationale supports the physician’s determinations.
• Clarifies ambiguous report questions with clients.
• Distribute final report back to client according to client specific requirements.
• Receives, coordinates & executes all aspects of clarification & addendum requests from the client.
• Participates in phone calls OR meetings with client(s) when a report is in question.
• Follow up with the client for any missing information that is pertinent to the referral.

Physician Interaction

• Works directly with physicians to ensure that all client questions are answered and supported by clinical rationale.
• Conduct regular follow up with the physician or their office staff to ensure an on-time delivery of the report.
• Compose and provide verbal or written feedback to the doctor regarding report quality.
• Compose and provide verbal or written requests to the physician or their office staff for clarifications.
• Receive written or verbal confirmation from the physician that a report has the doctor’s approval and ensures the doctor provides his/her signature for the final report.

Report Analysis

• Review each physician report for data accuracy including spelling, grammar & punctuation.
• Responsible for ensuring that all state requirements for reporting are met.
• Responsible for report format and adhering to each client’s specific requirements.
• Must ensure that all client special handling instructions with regard to report completion and delivery are met.

Additional Duties

• May provide oversight to the work of the team members.
• Continuously improves processes that help to facilitate better turnaround time, peer to peer success rates and lessens returned reports by clients for clarification purposes, ultimately resulting in higher client satisfaction.
• Responsible for the final approval on cases for release to the client.
• Will act as a liaison and coordinate quality issue reports along with all new reviewer reports with the VP of Clinical Operations.

Other duties & special projects, as assigned and based on business needs.

EDUCATION/CREDENTIALS

Associate’s or Bachelor’s Degree preferred. LPN or RN license required for this role..

JOB RELEVANT EXPERIENCE

Business experience in a healthcare and/or insurance setting is preferred.

JOB RELATED SKILLS/COMPETENCIES

Present exceptional communication skills with a clear understanding of company business lines. The ability to apply critical thinking, manage time efficiently and meet specific deadlines. Computer literacy and typing skills are essential.

WORKING CONDITIONS/PHYSICAL DEMANDS

Any lifting, bending, traveling, etc. required to do the job duties listed above. Long periods of sitting and computer work.

WORK FROM HOME TECHNICAL REQUIREMENTS

Supply and support their own internet services.

Maintaining an uninterrupted internet connection is a requirement of all work from home position.

This job description is subject to change at any time.