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Role Description

The QA Case Manager ensures the daily review process adheres to standardized company guidelines and, when applicable, client-specific requirements for billing and report documentation.

• Reviews all reports for professional content, correct coding, justification of billing entries and correct format.
• Assists with training of staff in appropriate medical and clinical content of reports and recording of data and statistics.
• Contacts case managers for corrections/additions/omissions.
• Forwards approved reports for final processing in a timely manner (volume dependent).
• Reviews invoices daily for appropriate billing entries.
• Contacts case managers for questions/issues; updates or documents changes, as necessary.
• Reports ongoing issues with billing and/or documentation to Senior Clinician.
• Assists in completion and administration of performance evaluations and QA statistics.
• Assists with file reviews on an ongoing basis and prior to yearly performance evaluations.
• Works closely regarding customer relations both positive and negative.
• Assists with corrective action plans.
• Assists with interviewing new case management personnel as necessary and as requested.
• Assures that case managers are utilizing one another for appointment coverage when necessary.
• Assists assigned case managers in distribution of workload during vacations/time off – Confirms coverage and notifies all customers.
• Coaches case managers on appropriate and accurate billing strategies.
• Attends team meetings as necessary and travels to the corporate office for essential meetings when scheduled.
• Assists in the collection of clinical statistics, inputting into appropriate systems and reports.
• Participates in staff meetings.
• Stays current with and informed of changes in case law, legislature and regulations that affect case management.
• Assists with orientation of newly hired employees related to billing and reporting.
• Assists and administers billing/documentation training programs for CM staff as appropriate.
• Assists in the development of procedures/policies.
• Assists with other management and operational tasks.

Qualifications

• Registered Nurse with current valid unrestricted state nursing license.
• Practice a health or human services discipline in a state or territory of the United States that allows the health professional to independently conduct an assessment as permitted within the scope of practice of the discipline.
• One or more National Certification/s CCM, CRC, CDMS, or others as defined by URAC preferred.
• Minimum of 5 years case management experience is preferred.

Requirements

• Remote with occasional travel if required for team meetings or industry events.
• Reports to: Senior Director of Case Management.

Benefits

• Competitive base salary + performance-based bonus.
• Comprehensive benefits package (healthcare, 401k, PTO, etc.).