The Quality Assurance Specialist plays a critical role in ensuring the accuracy, quality, and defensibility of independent medical examination (IME), peer review, and medical record review reports.
CorVel's IME division provides independent medical examinations, peer reviews, medical record reviews, document management, and related services to insurance carriers, self-insured employers, third-party administrators, law firms, and government agencies nationwide.
Responsibilities
- Conduct comprehensive quality assurance reviews of IME, peer review, medical record review, addendum, and supplemental reports
- Review reports for grammar, spelling, punctuation, formatting, medical terminology, and professional presentation
- Evaluate reports for overall clinical consistency, completeness, and defensibility
- Verify all client questions, referral issues, and case-specific instructions have been fully addressed
- Identify inconsistencies, unsupported conclusions, contradictory opinions, missing documentation, or gaps in medical reasoning
- Analyze causation opinions and ensure conclusions are supported by the medical evidence documented within the report
- Collaborate directly with physicians and consultants to obtain clarifications, corrections, or additional information when necessary
- Ensure compliance with client specifications, company standards, state mandates, and applicable federal requirements
- Verify provider credentials, board certifications, signatures, attestations, and conflict-of-interest statements as required
- Confirm appropriate citations, references, and evidence-based support are included when applicable
- Review reports for legal defensibility and consistency with referral documentation and medical records
- Assist in investigating, documenting, and resolving quality concerns, complaints, report rebuttals, and client escalations
- Participate in provider performance monitoring and communicate trends, concerns, and recommendations to management
- Identify opportunities for workflow improvement, quality enhancement, and operational efficiencies
- Support onboarding, training, and mentoring initiatives for new team members
- Maintain productivity and turnaround standards while ensuring a high degree of accuracy
- Participate in educational and training activities as required
- Maintain HIPAA compliance in all aspects of communications
- Perform additional duties as assigned
Requirements & Qualifications
Qualifications
- High school diploma or equivalent required
- Associate's or Bachelor's degree in healthcare administration, nursing, medical assisting, claims management, legal studies, or a related field preferred
- Or minimum 5 years of experience in one or more of the following areas:
- Independent Medical Examination (IME)
- Peer Review
- Medical Records Review
- Utilization Review
- Claims Management
- Case Management
- Medical Office Operations
- Quality Assurance
- Insurance Operations
- Strong understanding of medical terminology, anatomy and physiology, disease processes, medications, diagnostic testing, and treatment guidelines
- Ability to independently evaluate medical reports and identify inconsistencies, unsupported conclusions, missing information, or causation-related concerns
- Demonstrated critical thinking and analytical skills
- Excellent command of English language skills, including grammar, punctuation, and style
- Strong written and verbal communication skills
- Proficiency in Microsoft Word, Outlook, Excel, and web-based applications
- Ability to work independently, manage competing priorities, and meet deadlines
- Strong organizational skills with exceptional attention to detail
- Ability to maintain confidentiality and exercise sound judgment
- Comfort working in a fast-paced environment with changing priorities and deadlines
- Working knowledge of workers' compensation, auto liability, no-fault, disability, or related insurance programs preferred
- Experience reviewing complex medical, legal, insurance, or claims-related documentation preferred
Benefits & Perks
Benefits
- Medical (HDHP) with Pharmacy
- Dental
- Vision
- Long Term Disability
- Health Savings Account (HSA)
- Flexible Spending Account options
- Life Insurance
- Accident Insurance
- Critical Illness Insurance
- Pre-paid Legal Insurance
- Parking and Transit FSA accounts
- 401(k)
- Roth 401(k)
- Paid time off
Location
Madison, Wisconsin, US
Employment Type
Full-time
Experience Level
Intermediate Level
Remote work allowed
No
Posted
3 weeks ago