Utilization Review & Quality Assurance Specialist (32449)

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 - leveraging strong knowledge of group health plans, clinical criteria sets, leadership, and change management to review clinical documentation, uphold regulatory and client standards, and drive quality across medical review processes.

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.

• Must hold and maintain a Registered Nursing License.
• Strong knowledge of group health/criteria sets/leadership/change management.
• Must have strong understanding of medical terminology, anatomy and physiology, treatment protocols, medications and laboratory values.
• Must be proficient in Microsoft Office Suite, Outlook, internet navigation and general office equipment.
• Must have the ability to follow instructions and respond to upper managements’ directions accurately.
• Ability to work independently, prioritize tasks, and manage time efficiently in a fast-paced environment.
• Ability to demonstrate accuracy, thoroughness, and commitment to producing high quality work; actively monitor own performance and seek opportunities for improvement.
• Ability to demonstrate flexibility and remain composed under pressure or in stressful conditions; adapts well to change and promotes a positive team environment.
• Must be able to maintain confidentiality.
• Ability to follow all company policies and procedures in effect at time of hire and as they may change or be added from time to time.

ExamWorks is a leading provider of innovative healthcare services including independent medical examinations, peer reviews, bill reviews, Medicare compliance, case management, record retrieval, document management and related services. Our clients include property and casualty insurance carriers, law firms, third-party claim administrators and government agencies that use independent services to confirm the veracity of claims by sick or injured individuals under automotive, disability, liability and workers' compensation insurance coverages.

Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, pregnancy, genetic information, disability, status as a protected veteran, or any other protected category under applicable federal, state, and local laws.

Equal Opportunity Employer - Minorities/Females/Disabled/Veterans

ExamWorks offers a fast-paced team atmosphere with competitive benefits (medical, vision, dental), paid time off, and 401k.