Leading a movement where creativity delivers positive change. Learn more guidehealthcare.com.au
Clinical Quality Improvement Coordinator
Location
Illinois
Posted
1 day ago
Salary
$28 - $30 / hour
Seniority
Junior
Job Description
Clinical Quality Improvement Coordinator
Guide Healthcare
• Work in a fully remote environment and virtually engage with company and team in your daily work. • Subject Matter Expert (SME) on entire scope of QI measures, services, customers and quality initiatives under various commercial and governmental payers. • Conduct proactive patient outreach initiatives to identify and address quality gaps, engaging with patients to educate them on preventive care measures, schedule necessary screenings or appointments, and facilitate adherence to treatment plans, thereby contributing to improved health outcomes and closing quality gaps. • Collect quality data using various methods of data sourcing-EMR, claims, provider outreach. • Manage daily work using multiple systems and applications-EMR systems, payer portals, vendor platforms, Guidehealth applications, Microsoft 365 for Excel, Word and PowerPoint and Teams for messaging and meetings. • Work with patient lists, gap lists, sourced health data and medical records in your daily work. • Leverage all quality related resources to ensure accuracy and completeness of work measure/project instructions, NCQA/HEDIS® specifications, coding documents, quick reference guides. • Prioritize daily work to meet various quality reporting deadlines and requirements. • Communicate quality performances, barriers and improvement strategies both internally and with customers. • Follow all established policies and procedures for various QI workflows to ensure overall success. • Collaborate w/ customers, payers, co-workers to accomplish daily work. • Participate in all departmental and payer sponsored webinars/trainings/support calls throughout the year. • Communicate professionally and develop positive relationships with co-workers, customers, providers and providers’ support staff.
Job Requirements
- Associate degree or greater in related field or certified/licensed professional-CMA, LPN.
- Minimum 1-3 years of experience in healthcare setting; time spent working/charting/data abstraction via EMR system/s, knowledge of medical terminology, quality measures, medical billing/coding.
- Minimum 2 years’ experience in Medicare Advantage Quality data abstraction and patient outreach
- Tech savvy in managing the technical side of this position-working with health data, working in excel and PowerPoint, navigating multiple systems and applications.
- Highly skilled in verbal and written communications.
- Strong attention to detail, organized and ability to meet hard deadlines.
- Ability to collaborate w/ others and work effectively with management, co-workers, and customers.
Benefits
- Work from Home: Guidehealth is a fully remote company, providing you the flexibility to spend less time commuting and more time focusing on your professional goals and personal needs.
- Keep Health a Priority: We offer comprehensive Medical, Dental, and Vision plans to keep you covered.
- Plan for the Future: Our 401(k) plan includes a 3% employer match to your 6% contribution.
- Have Peace of Mind: We provide Life and Disability insurance for those "just in case" moments. Additionally, we offer voluntary Life options to keep you and your loved ones protected.
- Feel Supported When You Need It Most: Our Employee Assistance Program (EAP) is here to help you through tough times.
- Take Time for Yourself: We offer paid time off plans helping you achieve work-life balance and meet your personal goals.
- Support Your New Family: Guidehealth offers paid parental leave to give you the time you need.
- Learn and Grow: Your professional growth is important to us. Guidehealth offers various resources dedicated to your learning and development to advance your career with us.
Related Guides
Related Job Pages
More Clinical Coordinator Jobs
• Coordinate participant scheduling, visit execution, and follow-up across multiple studies • Support recruitment, screening, enrollment, and retention in patients with sleep disorders • Facilitate sleep-specific assessments (e.g., PSG, MWT, actigraphy) and PRO/eCOA completion • Ensure accurate, timely, and ALCOA+-compliant data entry and source documentation • Maintain study files and support ongoing inspection readiness • Assist with query resolution, data reconciliation, and monitoring visit preparation • Track and escalate protocol deviations, eligibility issues, and operational risks • Coordinate cross-functional communication between site, CRO and sponsor teams • Support IP handling and site logistics, as applicable • Assist with data entry into EDC as needed
Clinical Coordinator, Temporary
UMass Global Career BootcampsBreak into in-demand careers with UMass Global's Online Bootcamps in Software Engineering and Cyber Security.
• Liaison with local school districts. • Identify and contact schools/districts to place student teachers and other education credential candidates, in accordance with CTC requirements. • Assign University Clinical Supervisors to fieldwork students • Participate in training of University Clinical Supervisors • Follow up on evaluations of candidates and University Clinical Supervisors and district supervisors. • Conduct orientation with University Clinical Supervisors and candidates prior to commencing fieldwork. • Counsel and develop action plans for candidates who are experiencing difficulty in fieldwork. • Identify school districts needing agreements and notify the Central Office of any changes or issues.
Appeals Coordinator
Lifepoint HealthLifepoint Health is a leader in community-based care and driven by a mission of Making Communities Healthier. Our diversified healthcare delivery network spans 29 states and includes 63 community hospital campuses, 32 rehabilitation and behavioral health hospitals, and more than 170 additional sites of care across the healthcare continuum, such as acute rehabilitation units, outpatient centers and post-acute care facilities. We believe that success is achieved through talented people. We want to create places where employees want to work, with opportunities to pursue meaningful and satisfying careers that truly make a difference in communities across the country. We employ and provide care to people from all walks of life. We are committed to promoting healing, providing hope, preserving dignity and producing value with an inclusive workforce in which diversity is leveraged, respected, and reflective of the patients, family members, customers and team members we serve.
Role Description The Appeals Coordinator gathers all information required for an appeal, writes, and submits the appeal to the insurance company, makes follow-up phone calls, and maintains documentation of all steps taken. The Appeals Coordinator uses clinical criteria guidelines and clinical documentation to develop sound and well-supported appeal arguments to support medical necessity. The Appeals Coordinator works independently and collaboratively with other departments to positively affect clinical and financial outcomes. - Display knowledge of clinical pertinence and managed care requirements to support medical necessity criteria for inpatient and outpatient levels of care. - Verify the information needed by the insurance plan for an appeal, where to submit the appeal, and method of submitting appeal. - Manage large volumes of documents including copying, faxing and scanning incoming mail. - Document and log information on tracking systems and mainframe systems. - Ensure appeals are completed thoroughly and on a timely basis. - Interface with managed care organizations, external reviews, and other payers. - Obtain access to various provider portals and utilize portals for submitting appeals and following up on status of appeals when applicable. - Communicate with facility UR staff when needed to efficiently complete the appeal process. Qualifications - Bachelor’s Degree in social work, RN or degree in a related behavioral health field. - Minimum of 2 years of experience in a managed care/healthcare setting. Requirements - Previous utilization review experience in a psychiatric healthcare facility preferred. - Computer proficiency in Microsoft Office applications and other software programs essential to perform job functions. - May be required to work flexible hours and overtime. Benefits - Comprehensive Benefits: Multiple levels of medical, dental and vision coverage for full-time and part-time employees. - Financial Protection & PTO: Life, accident, critical illness, hospital indemnity insurance, short- and long-term disability, paid family leave and paid time off. - Financial & Career Growth: Higher education and certification tuition assistance, loan assistance and 401(k) retirement package and company match. - Employee Well-being: Mental, physical, and financial wellness programs (free gym memberships, virtual care appointments, mental health services and discount programs). - Professional Development: Ongoing learning and career advancement opportunities.
• Investigate and process medical necessity requests from both members and providers • Conduct and lead investigations and reviews for member and provider medical necessity appeals • Review the medical record of denied services for medical necessity • Provide a summary of case for the medical director, and other partners in the health plan care team • Ensure that appeal timeframes are met and meet the standards of enterprise, state, and federal standards and requirements • Document and log case information for the appeal • Generate the written response to the member or provider • Serve as a subject matter expert for appeals and grievances


