About this role
Your Role
The Clinical Quality Review (CQR) team investigates and reviews potential quality of care issue(s) (PQI) or concerns arising from member grievances and internal referrals. PQI reviews may confirm a quality problem that resulted in, or had the potential for harm, to the member and can lead to identification of provider opportunities for improvement related to practice patterns that are outside the framework of accepted standards. The Clinical Quality Coordinator will report to the Sr. Manager, Clinical Quality Review. In this role you will be primarily responsible for requesting medical records and responses from providers as directed to facilitate clinical review by CQR staff.
Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.
Your Work
In this role, you will
- Request medical records and/or response requests from providers fax, secure email, or remote electronic medical record system
- Validate provider contact information and update department repository accurately
- Follow up on medical records and/or response requests via phone or email and implement appropriate action
- Manage incoming medical records/responses accurately and timely
- Review medical records upon receipt for content prior to sending for clinical review
- Follow up with provider if records are incomplete
- Consult with CQR Lead/RN as needed on requests and request status
- Prioritize tasks and assignments to meet turnaround time goals
- Research provider and member information using internal applications (claims, PCP information, plan type)
- Be an active team member and promote a positive work environment
- Provide input for continuous process improvement
- Enter accurate data into department database to ensure accurate reporting
- Work under limited to moderate supervision on routine tasks
- Deliver on day-to-day objectives which impact the overall of department goals
- May provide guidance and assistance to new or entry level staff
- Participate in audit preparation activities
Your Knowledge and Experience
- Requires a High school Diploma or GED or 1 year of additional relevant experience in lieu of a diploma
- Requires 3 years of prior relevant experience
- Strong verbal and written communication skills
- Basic knowledge of PC-based software including Microsoft Suite and Adobe Acrobat
- Basic knowledge of managed care principles and benefit plans per line of business (HMO, PPO, Medicare) preferred
- Basic knowledge of regulatory and accreditation agencies (DMHC, DHCS, CMS, NCQA) preferred
Hybrid Virtual Work
This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.