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 under-served communities.

Best People, Best Solutions, Best Results

Job Summary: Performs clinical assessment functions of the review program as outlined by procedures, by conducting an initial screening for the Expert Reviewer/Medical Director. This review may be performed prior to admission, concurrently, or retrospectively, depending on contract requirements. May work on any contract for which training has been provided.

Essential Duties and Responsibilities:

• Reviews medical records to determine medical necessity, appropriateness of utilization and/or coding and quality issues in accordance with pre-established criteria.
• Refers potential adverse decisions to the Expert Reviewer/Medical Director for peer review.
• Performs on-line data entry of review results concurrently, utilizing appropriate codes and information outlined in Qlarant's procedures.
• Responsible for case specific or plan specific reports, which includes but is not limited to technology systems.
• Completes inquiry letters and final determination letters, case summaries, and provider performance reports.
• Completes the notification process, when required, including inquiry letters and final determination letters.
• Completes coding validation on each applicable case, after appropriate training.
• Participates in internal and external focus groups, as required, for feedback purposes.
• Interacts with customers on-site and by phone, explaining the results of the reviews, and identifies issues that should be referred for resolution.
• Identifies opportunities to improve processes and procedures.
• Has the responsibility and authority to perform their job and provide customer satisfaction.
• Within contract constraints, instructions and established procedures have some ability to interpret guidelines and choose from alternative courses of action.
• Familiar with commonly used concepts, practices and procedures, relying on instructions and pre-established guidelines to perform the functions of the job.

Supervisory Responsibilities

This job has no supervisory responsibilities

Analytical - Synthesizes complex or diverse information; Collects and researches data; Uses intuition and experience to complement data.

Problem Solving - Gathers and analyzes information skillfully.

Customer Service - Responds promptly to customer needs; Responds to requests for service and assistance; Meets commitments.

Quality Management - Looks for ways to improve and promote quality; Demonstrates accuracy and thoroughness.

Judgment - Supports and explains reasoning for decisions.

Must possess at least two years clinical experience that demonstrates expertise in reading utilization reviews, ICD-9 coding, CPT coding, Pharmacy Tech, Dental Hygienist, Licensed Practical Nurse and/or interpreting Medicare or Medicaid claims data.

Qlarant, Inc is an Equal Opportunity Employer of Minorities, Females, Protected Veterans, and Individuals with Disabilities.

*Note: Qlarant has a mandate as a Federal contractor that all associates must be fully vaccinated with one of the approved COVID vaccines.*