IDRE Quality Specialist
New
N
North Haven Government Services SolutionsHealthcare dispute resolution
Workable workplace: remote; Workable locations: United StatesFull-Time
Salary not disclosed
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Job Details
- Required Skills
- Quality AssuranceHIPAA
Requirements
- An LPN, associate’s degree, or bachelor’s degree is preferred.
- Relevant professional experience may be considered in lieu of a degree.
- Business experience in a healthcare or insurance setting is preferred.
- Be organized and detail-oriented and able to manage multiple priorities in a deadline-driven environment.
- Apply sound judgment and problem-solving abilities and maintain a commitment to accuracy.
- Communicate effectively and professionally with customers, reviewers, and management.
Responsibilities
- Review reviewer reports for accuracy, completeness, and adherence to customer requirements, company standards, and clinical guidelines.
- Evaluate dispute rationales and determinations for compliance with internal and CMS guidelines.
- Assess whether rationales are logical and conclusions are based on sound assumptions.
- Identify discrepancies, missing information, and opportunities for improvement in the review process.
- Follow up with arbiters to obtain pertinent or missing information.
- Coordinate with customers, reviewers, and management to resolve questions and deficiencies and facilitate timely report completion.
- Ensure reports meet quality standards and are submitted to CMS within required deadlines.
- Handle communications involving HIPAA and PHI securely and in accordance with applicable privacy and confidentiality requirements.
- Contribute to process improvement initiatives focused on quality, efficiency, and turnaround times.
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