Remote Optum Utilization Review Jobs in Michigan

The Clinical Quality Assurance Manager plays a crucial role in Centria's efforts to ensure proper implementation of all clinical quality standards. This role will be responsible for reviewing clinical documents to evaluate their adherence to Centria's quality standards and summarizing the findings for internal stakeholders. Working closely with the Director of Clinical Quality, they will also provide guidance and support to the Clinical Quality Assurance Specialists, mentor new team members during their orientation to the team, and co-reviewing records for interobserver agreement.

1. Support Quality Assurance Department Clinical Review Activities
   • Process requests; obtain documents and compile information for clinical review requests.
   • Report on and provide routine feedback in a quantitative format on adherence to Centria clinical quality standards, as measured by the clinical reviews.
   • Log details of the review request in a trackable format to allow real-time viewing of progress.
   • Store and catalog all review materials for future review if required.
   • Work across multiple internal systems to ensure clinical reviews are comprehensive and accurate.
   • Coordinate with clinical staff and other departments to obtain required documentation.
   • Collaborate with other departments to ensure appropriate escalations, collaboration, and stakeholder inclusion.
   • Provide feedback to inform potential areas of improvement.
   • Monitor adherence to clinical quality elements of payor Corrective Action Plans and assist clinical and operational leaders with preparation for future clinical reviews.
   • Remain up to date and trained on all necessary information systems to ensure the full breadth of a process can be examined.
   • Compile and generate various reports related to clinical quality standards as required by the Clinical Excellence Department (CED), including staffing lists, utilization reports, inactivity reports, status updates, etc.
   • Gather information and conduct analysis to ensure compliance with and smooth reviews by third party credentialing organizations (e.g., JCAHO, BHCOE).
2. Clinical Quality Assurance Specialist Support
   • Assist with other clinical quality measures, such as client satisfaction surveys.
   • Participate in the implementation of new clinical quality initiatives and processes.
   • Assist with ad hoc reports as needed.
   • Support teammates in onboarding and ongoing mentorships.
   • Conduct co-reviews to ensure interobserver agreement using Centria rubrics.

$80,000 - $85,000 per year

• Bachelor's degree
• Master's degree, preferred
• BCBA or BCaBA certification

• Knowledge of ABA clinical and documentation best practices, preferred
• Knowledge of ABA terminology and clinical concepts, preferred
• Proven record of success in working in a highly detail-oriented environment

• Basic computer skills
• Working knowledge of laptop/desktop PC
• Proficiency in Microsoft Suite
• Proficiency in G Suite

• Ability to follow written instructions
• Ability to use computers and computer/software programs
• Ability to communicate expressively and receptively

• Excellent communication skills, both written and verbal;
• Data-driven with an aptitude for interpreting results and firm adherence to process;
• Comprehensive understanding of payor requirements and proficiency in navigating CareConnect;
• Track record of success in clinical review or payor clinical review responses;
• Knowledge of ABA clinical best practices, including PFA/SBT;
• Strong understanding of Centria operational processes with the ability to work collaboratively with other departments in collecting documentation;
• Knowledge of computer systems related to clinical, and operational functions;
• Knowledge of clinical review and compliance process;
• Knowledge of medical terminology and clinical concepts;
• Ability to organize, prioritize and handle multiple tasks, adhere to established deadlines, and produce work that consistently meets or exceeds team benchmarks;
• Proven adaptability with a willingness to work both collaboratively and individually to achieve desired business outcomes;
• Demonstrated strong work ethic with attention to detail, accuracy, and quality;
• Established track record of generating error-free work.

• Centria's office hours are Monday through Friday from 8:30 AM - 6:00 PM.
• Additional time or occasional shift in schedule may be required to complete the above work or meet company objectives.

While performing the duties of this job, physical requirements such as bending, reaching, lifting, pushing, or pulling up to 30 pounds may be required. This role will require sitting most of the day as well as walking and standing periodically. This role may require close visual acuity on computer screens or monitors and the ability to analyze data and figures on a screen.

We are an equal opportunity employer and value diversity at our company. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, Veteran status, or disability status. This job description is not intended to be an exhaustive list of qualifications, skills, efforts, duties, responsibilities, or working conditions associated with the position. Centria reserves the right to amend this job description at any time, with or without written notice.