MR/PI Coordinator I

Qlarant is a not-for-profit corporation that partners with public and private sectors to create high quality, safe, and efficient delivery of health care and human services programs. We have multiple lines of business including population health, utilization review, managed care organization quality review, and quality assurance for programs serving individuals with developmental disabilities. Qlarant is also a national leader in fighting fraud, waste and abuse for large organizations across the country. In addition, our Foundation provides grant opportunities to those with programs for underserved communities.

Best People, Best Solutions, Best Results Job Summary:

Coordinates and maintains operational activities related to the medical review and/or program integrity processes.

Essential Functions:

Implements, revises, and removes claims system edits. Works within the Medicare claims processing systems to monitor the status of UPIC initiated edits. Sends out correspondence such as educational letters, prepay notification letters, and suspension correspondence. Responds to client inquiries via written or verbal communications. Monitors and creates reports that show the results of system edits and presents these findings at the Prepay Committee Meetings. Initiates and maintains communication with the UPIC legal team, RFI Coordinator, and Law Enforcement to manage the transfer of case/investigation information. Works closely with the UPIC legal team in response to FOIAs, RFIs, ALJ Hearings, Congressional Complaints, and other related activities. Tracks and creates reports related to the results of upper level appeals. Works within internal and external tracking systems to monitor the status of payment suspensions, zone restrictions, and other cases or investigations as assigned. Monitors and creates reports that indicate monitoring of identified administrative actions. Attends the UPIC Medical Review meetings and updates tracking systems with information from the meeting. Coordinates and manages the transition of workloads, and serves as the interface with other entities. Provides training and technical advice to team members. Works with Quality Director/Officer on ISO initiatives to improve operational systems, processes, and policies to improve information flow, management reporting, business process, and organizational planning.

Level of Supervision Received:

Under close supervision, works closely with manager to prioritize efforts Education (can be substituted for experience): Minimum High School Diploma or GED required Work Experience (can be substituted for education): 0 - 2 years of experience required; 2 - 4 years preferred Qlarant is an Equal Opportunity Employer of Minorities, Females, Protected Veterans, and Individuals with Disabilities. Qlarant is a drug-free workplace. All offers of employment are contingent upon successful completion of pre-employment background and drug screens.