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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in quality assurance reviews, clinical documentation, and compliance with federal and state mandates. Proficient in medical terminology and peer review processes, ensuring accurate and thorough evaluations.
Highest-signal resume keywords
Quality Assurance ReviewsClinical Documentation ReviewPeer Review ExperienceKnowledge of CMS GuidelinesMedical Terminology
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical Documentation ReviewMedical Necessity AssessmentsArithmetic ComputationTyping Speed of 40 W.P.M.Microsoft WordMicrosoft OutlookMicrosoft ExcelInternet Proficiency
Soft Skills
Exceptional Communication SkillsAbility to Follow InstructionsAccuracy and ThoroughnessTime Management
Tools & Technologies
ComputerFax MachineCopierScannerTelephone
Industry Keywords
ERISA CompliancePeer Reviewer AttestationsManaged Care OrganizationsInsurance CarriersTPAs
About the role
Key responsibilities & impact- Perform quality assurance reviews of peer review reports, correspondences, addendums, and supplemental reviews
- Ensure clear, concise, evidence-based rationales support recommendations and determinations
- Verify client instructions, specifications, and questions are addressed
- Verify clinical citations and references are current and reputable
- Ensure report content, format, and professional appearance meet company standards
- Ensure appropriate board specialty review and documentation comply with client specifications or state mandates
- Verify peer reviewer attestations and absence of conflicts of interest
- Ensure provider credentials and signatures are included in final reports
- Identify report inconsistencies and contact peer reviewers for clarification or correction
- Assist with client complaints and quality assurance issues
- Ensure compliance with federal ERISA and state mandates
- Provide management insight on consultant quality, availability, and compliance
- Promote effective and efficient use of company resources
- Participate in educational and training activities
- Perform other assigned duties
Requirements
What you’ll need- High school diploma or equivalent required
- Minimum of two years clinical or related field experience, or equivalent combination of education and experience
- Experience in peer review, clinical documentation review, or medical necessity assessments
- Familiarity with CMS guidelines, InterQual, Milliman/MCG, or payer policies
- Prior employment with insurance carriers, TPAs, or managed care organizations
- Strong knowledge of medical terminology, anatomy and physiology, medications, and laboratory values
- Ability to perform arithmetic with whole numbers and decimals and compute rates and percentages
- Qualified typist with a minimum of 40 W.P.M.
- Ability to operate a computer, fax, copier, scanner, and telephone
- Knowledge of Microsoft Word, Outlook, Excel, and the Internet
- Excellent English usage, grammar, punctuation, and style
- Ability to follow instructions accurately
- Accuracy, thoroughness, and quality-monitoring skills
- Exceptional communication skills
- Ability to work independently, prioritize work, and use time efficiently
- Ability to maintain confidentiality
Benefits
Comp & perks- 100% remote work from home
- Medical, vision, and dental benefits
- Paid time off
- 401k
- Fast-paced team atmosphere
- Monday to Friday schedule, 8:30am–5:00pm EST