Utilization Review & Quality Assurance Specialist (31813)

Are you passionate about clinical quality, accuracy, and continuous improvement -and looking for a role that allows you to make a meaningful impact while working from home?

We’re seeking a Utilization Review & Quality Assurance Specialist to join our fully remote team. This role offers a consistent 8:00am-4:30pm EST schedule, providing structure and work-life balance while you contribute to high‑quality clinical review operations.

In this role, you’ll be at the center of ensuring excellence - reviewing clinical documentation, upholding regulatory and client standards, and driving quality across medical review processes.

If you thrive in a peer review environment, have a sharp analytical mindset, and take pride in delivering precise, compliant, and thoughtful work, this is an exciting opportunity to grow your expertise and help shape best practices in utilization review and quality assurance.

Responsibilities may include

• Evaluate clinical information received, write and/or review various reports including, but not limited to: Medical Record Reviews, Medical Record Chronologies, Provider Bill Reviews, Coding Reviews, Hospital Bill Reviews, List of Missing Records, Medical Bill Apportionments, Mock Billing Invoice and Medical Summary Statements.
• Perform quality assurance reviews of peer review reports, correspondences, addendums or supplemental reviews to ensure they meet company standards for content, clarity, evidence-based rationale, formatting, and professional presentation.
• Ensure all client instructions and specifications have been followed, all questions have been answered, and all recommendations or determinations are supported by clear, concise, and evidence-based rationales.
• Verify that each review includes appropriate clinical citations when applicable, and ensure all references cited are current and obtained from reputable medical journals and publications.
• Identify inconsistencies within reports and contact the reviewer to obtain clarifications, modifications, or corrections needed.
• Assist in the resolution of customer complaints and quality assurance issues as appropriate.
• Ensure all federal ERISA and applicable state mandates are adhered to.
• Provide ongoing feedback and recommendations to management regarding consultant performance, quality trends, and compliance with internal and client specific requirements.
• Participate in the development and implementation of policies and procedures to improve efficiency and quality across operations.
• Develop and lead formal and informal training sessions -individually or in groups -that promote high-quality utilization review practices and reinforce company standards.
• Develop and document new or improved operational processes to support continuous improvement.
• Promote effective and efficient utilization of company resources across all responsibilities.
• Participate in or lead various continuing education and training activities related to clinical knowledge, industry standards, and company processes.
• Perform other duties as assigned.