Job Summary

The Quality Review Specialist is responsible for quality assurance and utilization review of medical records and Patient-Centered Service Plans, preparation and review of audit reports. The Quality Record Review Specialist also provides general support for all EQR programs as needed.

Essential Duties and Responsibilities

1. Provide a detail-focused review of clinical documentation to ensure quality regulatory compliance and audit readiness.
2. Detail-focused review of enrollee care plans for compliance with standards and appropriateness.
3. Assist in aggregating results for reporting and report review.
4. Maintain HIPPA/Security Training requirements.
5. Review Medical & Dental records and claims data for completeness and accuracy of CDT/CPT codes.
6. Provide general support for all EQRO contracts as needed.
7. Additional duties as requested by the EQRO Director.

Knowledge, Skills & Abilities

1. Proficient computer skills (MS Word, Excel, PowerPoint).
2. Excellent oral, written, and customer service-oriented communication skills.
3. Excellent and demonstrated criticalthinking ability.
4. Excellent organizational skills with the ability to respond to and coordinate multiple activities simultaneously under short time frames.
5. Customer service oriented when working with internaland external customers.

Education, Experience, & Licensing Requirements

Education

1. High School diploma or equivalent required.

Experience

1. One (1) to Three (3) years of Medicaid or Managed Care documentation and audit experience preferred.

Travel Requirements

1. Employee will work remotely from a home-based office. Approximately 25% travel is required.

Physical Requirements

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

1. Employee will constantly communicate with others regarding employment related information or instruction and must be able to exchange accurate information in these situations.
2. This role requires constant use of standard office equipment such as computers and telephones to receive and share information.
3. Employee must be able to read and interpret information displayed on a computer screen.
4. Employee must be able to remain in a stationary position for extended periods of time.
5. This role occasionally requires the employee to lift light objects up to 25 pounds.