IDRE Quality Specialist
Job Description
IDRE QA Specialist
North Haven Government Services Solutions
North Haven Government Services Solutions is seeking a skilled and detail-oriented IDRE QA Specialist to join our growing Operations team. This is an important role within our Independent Dispute Resolution (IDR) process, ensuring the accuracy, completeness, and timely delivery of reports to the Centers for Medicare & Medicaid Services (CMS).
The QA Specialist serves as a key point of coordination between customers, reviewers, and management, helping ensure that each completed reviewer report meets established requirements and is delivered within required timeframes.
What We're Looking For
The ideal candidate is highly organized, detail-oriented, and able to manage multiple priorities in a deadline-driven environment. Strong communication skills, sound judgment, problem-solving abilities, and a commitment to accuracy are essential.
North Haven Solutions values innovation, collaboration, accountability, and integrity. We offer an engaging work environment where your contributions make a meaningful difference. If you are looking for a challenging and rewarding opportunity with room for professional growth, we invite you to join our team and help us deliver excellence without exception.
IDRE QA SpecialistNorth Haven Government Services SolutionsNorth Haven Government Services Solutions is seeking a skilled and detail-oriented IDRE QA Specialist to join our growing Operations team. This is an important role within our Independent Dispu...Key Responsibilities
Review reviewer reports for accuracy, completeness, and adherence to customer requirements, company standards, and applicable clinical guidelines.
Coordinate and communicate effectively with customers, reviewers, and management to resolve questions, address deficiencies, and facilitate timely report completion.
Ensure reports meet established quality standards and are submitted to CMS within required deadlines.
Identify discrepancies, missing information, and opportunities for improvement throughout the review process.
Maintain a strong understanding of company processes, quality expectations, and applicable IDRE requirements.
Contribute to continuous process improvement initiatives designed to enhance quality, efficiency, and turnaround times.
Work collaboratively with the Operations team to support the company's continued growth and operational success
Evaluates the Quality of the dispute rationale/ determination to ensure that all requirements have been met in compliance with internal and CMS guidelines.
Follow up with the arbiters for any pertinent and missing information
Assess whether the rationale is logical and the conclusions are based on sound assumptions
Maintain professionalism and courtesy when responding to emails and other communications, while ensuring all communications involving HIPAA and PHI are handled appropriately, securely, and in accordance with applicable privacy and confidentiality requirements.
Educations/Credentials:
An LPN, Associate’s or Bachelor’s degree is preferred; relevant professional experience in lieu of a degree may be considered.
Job Relevant Experience:
Business experience in a healthcare and/or insurance setting is preferred. :
