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.

Dane Street’s success relies on individual and team contributions every day. We care for our customers, each other and Dane Street. It is the responsibility for all of us to maintain a positive working environment that promotes client satisfaction and results.

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. 

Requirements

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.

Benefits

Join our team at Dane Street and enjoy a comprehensive benefits package designed to support your well-being and peace of mind. We offer a range of benefits including medical, dental, and vision coverage for you and your family. Additionally, we offer voluntary life insurance options for you, your spouse, and your children. We also offer other voluntary benefits which include hospital indemnity, critical illness, accident indemnity, and pet insurance plans. Employees receive basic life insurance, short-term disability, and long-term disability coverage at no cost. Our generous paid time off policy ensures you have time to relax and recharge, while our 401k plan with a company match helps you plan for your future. Apple equipment and a media stipend are provided for remote workspace. 

ABOUT DANE STREET:

A fast-paced, Inc. 500 Company with a high-performance culture, is seeking insightful forward-thinking professionals. We process over 200,000 insurance claims annually for leading national and regional Workers’ Compensation, Disability, Auto, and Group Health Carriers, Third-Party Administrators, Managed Care Organizations, Employers, and Pharmacy Benefit Managers. We provide customized Independent Medical Exams and Peer Review programs that assist our clients in reaching the appropriate medical determination as part of the claims management process.