About iMPROve Health

Come join the iMPROve Health team! iMPROve Health is Michigan’s Medicare-designated Quality Improvement Organization. We are both a Cool Place to Work (Crain’s Detroit Business), one of the Best Places to Work in Healthcare, and one of the Best Nonprofits to Work For as judged by Modern Healthcare. As a nonprofit organization, we have 40 years’ experience improving healthcare across the continuum of care using evidence-based and data-driven logic. iMPROve Health provides medical consulting and review, as well as data analysis to federal agencies, state Medicaid and public health organizations, healthcare facilities, private health plans and other third-party payers. We also have extensive experience completing thoughtful and impartial utilization review, dispute resolution and peer reviews. Our goal is simple – to help healthcare get better!

This position is 100% remote and provides the opportunity to work virtually with team members from anywhere within the United States. We pride ourselves on providing a great work/life balance for employees, while also providing the ability to promote their career development and gain new skills through employee education opportunities. iMPROve Health offers a wonderful benefit package that includes medical, dental, vision, life insurance, short term and long-term disability, and a generous 401k match.

iMPROve Health is committed to improving the quality, safety, and efficiency of healthcare. Although we do not see patients, we are healthcare professionals (including physicians and nurses) and consultants who work with healthcare providers to promote the adoption and use of evidence-based best practices and processes to achieve our healthcare quality goals. Our services offer our clients and partners access to a proven, impartial, connected resource that understands the intricacies of healthcare. It is our #1 priority to provide thoughtful evidence-based strategies and solutions that help them achieve their healthcare quality improvement goals and outcomes.

iMPROve Health is an equal employment opportunity employer.

*Must be able to work M-F normal business hours in EST.

SUMMARY:

Responsibilities include completing IDR/IIDR/IDRE reviews as assigned and determined by contractual obligations. Ensures services are provided within URAC accreditation program for Independent Review Organization standards.

DUTIES AND RESPONSIBILITIES:

• Responsible for the successful completion of assigned contract deliverables according to contract requirements.

• Expectation:

Demonstrates capacity and successfully takes on varied assignments related to current contracts. Meets deliverable deadlines with high quality products.

• Develops and monitors timelines and work plans relevant to assigned tasks.

• Expectation:

Utilizes time and project management skills to ensure assigned activities are completed in a timely manner and in accordance with contract requirements. Applies problem solving abilities to identify, resolve and/or communicate potential delays or problems in advance of deadlines.

• Accurate and timely data entry into designed CMS system and department data base.

• Expectation:

Able to accurately complete data entry on all case review intake according to contract guidelines and timeframes.

• Manage and process all incoming and outgoing COI Case Reviews.

• Expectation:

Adhere to all security guidelines for safe transmission of COI case reviews. Process them in a timely, efficient manner.

• Adheres to all relevant compliance regulations (HIPAA, FISMA, URAC, CMS).
  • Expectation:

Maintains up to date knowledge, training and adherence with all compliance and regulatory requirements for contracts, governmental and compliance regulatory organizations.

• Other duties as assigned

QUALIFICATIONS:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. This includes abilities needed to perform any regular duty, regardless of how often the duty is performed. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The individual must have relevant experience and knowledge in long-term care, assisted living facilities, ICF/IID facilities, and/or other health care services of the applicable State and Federal regulations for the above referenced facilities and/or providers. The individual performing the reviews must have regulatory expertise and experience in areas that include nursing, social work, life safety codes, and/or CMS state surveyor training.

EDUCATION AND/OR EXPERIENCE:

• Bachelor’s Degree or equivalent years of experience in utilization review or case management experience required
• Nursing or related licensure and accreditation with continuing education preferred but not required
• Utilization and/or healthcare and/or case management experience preferred
• Excellent communication skills
• Excellent customer service skills