Clinical Quality Coordinator, Intermediate

DescriptionYour Role The Clinical Quality Review (CQR) team investigates and reviews potential quality of care issue(s) (PQI) or concerns arising from member grievances and internal referrals. PQI reviews may confirm a quality problem that resulted in, or had the potential for harm, to the member and can lead to identification of provider opportunities for improvement related to practice patterns that are outside the framework of accepted standards. The Clinical Quality Coordinator will report to the Sr. Manager, Clinical Quality Review. In this role you will be primarily responsible for requesting medical records and responses from providers as directed to facilitate clinical review by CQR staff.  Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.The Clinical Quality Review (CQR) Department investigates and reviews potential quality of care issue(s) (PQI) or concerns arising from member grievances and internal referrals. PQI reviews may confirm a quality problem that resulted in, or had the potential for harm, to the member and can lead to identification of provider opportunities for improvement related to practice patterns that are outside the framework of accepted standards. The Clinical Quality Coordinator will report to the Clinical Quality Review Manager. In this role you will be primarily responsible for requesting medical records and responses from providers as directed to facilitate clinical review by CQR staff.   ResponsibilitiesYour Work In this role, you will: Request medical records and/or response requests from providers fax, secure email, or remote electronic medical record system   Validate provider contact information and update department repository accurately   Follow up on medical records and/or response requests via phone or email and implement Manage incoming medical records/responses accurately and timely Review medical records upon receipt for content prior to sending for clinical review   Follow up with provider if records are incompleteConsult with CQR Lead/RN as needed on requests and request status  Prioritize tasks and assignments to meet turnaround time goals   Research provider and member information using internal applications (claims, PCP information, plan type)    Be an active team member and promote a positive work environmentProvide input for continuous process improvement   Enter accurate data into department database to ensure accurate reporting  Work under limited to moderate supervision on routine tasks     Deliver on day-to-day objectives which impact the overall of department goals May provide guidance and assistance to new or entry level staff Participate in audit preparation activities QualificationsYour Knowledge and Experience Requires a high school diploma or GEDRequires basic job knowledge of systems and procedures obtained through prior work experience or educationTypically, requires a minimum of 3 years of prior relevant experienceStrong verbal and written communication skills    Basic knowledge of PC-based software including Microsoft Suite and Adobe AcrobatBasic knowledge of managed care principles and benefit plans per line of business (HMO, PPO, Medicare) preferredBasic knowledge of regulatory and accreditation agencies (DMHC, DHCS, CMS, NCQA) preferredHybrid Virtual WorkThis role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.