Onboard and train all new QA hires. - New QAs will be ready for integration into the ops team when the following criteria are met:
Proficiency on one core client (≤ 2% clarification rate)
Division 1: HCSC
Division 2: BCBS MN
Division 3: Optum
Daily output of ≥ 5 cases
Collaborate on the review of daily operational reports (e.g., outcome reports, TAT, operational synopsis, employee goals). - Serve as a resource for team members regarding operational questions, concerns, and problem-solving. - Provide backup support to QA Supervisors as needed (e.g., invoicing, board balance). - Maintain weekly clarification tracker; identify QAs with opportunities for additional training or feedback. - Participate in client calls. - Lead bi-weekly Clarification/TAT review meetings: pull data, facilitate discussions, and issue remediation plans. - Conduct regular MFR (member-friendly rationale) Workshop training sessions. - Develop onboarding agendas in consultation with Ops Leadership. - Identify and schedule training opportunities/meetings. - Coordinate and track annual client regulatory training requirements. - Support regulatory accreditation audits (e.g., NCQA, URAC). - Provide backup support to GH Auditor in performing client collaboration audits (e.g., BCBSMN monthly, HCSC quarterly and annual). - Update and maintain severity and client-change trackers. - Create and maintain training documentation. - Collaborate on remediation plans for employees. - Provide reviewer training when a Medical Director is unavailable; escalate issues to Medical Directors when appropriate. - Partner with managers and supervisors to support 90-day reviews, annual evaluations, and PIPs. ## Requirements
Qualifications:
RN or LPN license required. - Strong background in clinical operations, training, or quality assurance. - Extensive experience in utilization review, with a strong background in health plan practices. - Experience navigating CMS requirements, health plan criteria, and nationally recognized guidelines such as MCG and InterQual. - Proficient in rationale writing and translation to patient-friendly language. - Excellent communication, coaching, and mentoring skills. - Ability to analyze data and identify trends to drive performance improvements. - Skilled in client collaboration and escalation management. - Proficiency with Google Suite, communication platforms, and related applications. Preferred Experience Includes:
Benefit Denials
Medical Necessity Reviews
EIU Reviews
Criteria-Only Reviews
Formulary Exception Reviews
Quantity Limit Reviews
Step Therapy Reviews
Inpatient vs Observation Reviews
Level of Care Reviews
Claims Reviews
Payment Integrity Reviews
DRG Validation
Quality of Care Reviews
Fraud, Waste, and Abuse (FWA) Reviews
JOB RELATED SKILLS/COMPETENCIES:
Extensive working knowledge of relevant guidelines. Excellent understanding of medical terminology, critical thinking, ability to manage time efficiently and to meet specific deadlines. Present exceptional communication skills with a clear understanding of company business lines. Computer literacy and typing skills are essential. ## 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.
