Job Description: Your Role The Clinical Quality Review (CQR) team is responsible for reviewing potential quality... of care issues (PQIs) reported by a member, a member representative, or an internal partner. The Clinical Quality Review (CQR...
management and reviews of department work process documents. The ideal candidate will have previous leadership experienced, hold... such as Medicare and Med-Cal, including dual-eligibility products. Conducts clinical review of claims for medical necessity, coding...
. You will also be responsible for quality audits, inventory management and reviews of department work process documents. The ideal candidate.... Conducts clinical review of claims for medical necessity, coding accuracy, medical policy compliance and contract compliance...
years of supervisory experience Engages in strong time-management skills Communicates effectively and professionally..., mentors, and colleagues of various clinical backgrounds, cultures, and experiences A hands-on and personable CEO...
Manage multiple vendor contracts for nonprofit association clinical guidelines and training Drive Utilization Management... system enhancements to accommodate updated and/or new clinical guidelines Represent Utilization Management during internal...