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MCMC Services, LLC · 17 hours ago

Clinical Quality Assurance Coordinator - Supervisor

United States

Full-time

Remote

Senior Level

MCMC Services, LLC is seeking a Clinical Quality Assurance Coordinator - Supervisor to lead and enhance their Quality Assurance Department. This role involves overseeing daily operations, ensuring quality standards, and providing leadership to a dedicated team.

Health CareHospital

Responsibilities

Coordinate and direct the QA department’s daily workflow to ensure all product lines are completed with the highest level of quality in the most effective and efficient manner possible

Prioritize and manage the daily workload and ensure the appropriate and equitable distribution of work is maintained in order to achieve goals

Monitor work product to ensure clear, concise, evidence-based rationales have been provided in support of all recommendations or determinations and that specific indicators and criteria in accordance with company policy and procedures have been achieved

Ensure department compliance of all federal ERISA and state mandates is adhered to at all times

Promote effective and efficient utilization of all clinical resources and makes necessary recommendations for improvements to management as needed

Ensure all client relationships are maintained and all client specific requirements are met

Assist promptly in resolution of any physician and/or customer complaints or quality assurance issues

Delegate work as needed and provide backup to all departmental positions as required

Provide insight and direction to management on consultant quality, availability and compliance with all company policies and procedures

Participate in the development and implementation of policies and procedures in order to promote and achieve the most efficient operation possible

Participate in various educational and or training activities as required

Perform other duties as assigned

Qualification

Fraud detection expertiseCPTHCPCSICD-10 knowledgeClaims data analysisSupervisory experienceCompliance knowledgeCoaching abilityInvestigative practicesHealthcare fraud certificationsCommunication skillsTeam collaboration

Required

Experience supervising or leading investigations within a Group Health SIU or medical claims environment

Strong knowledge of fraud, waste, and abuse (FWA) detection and investigative practices

Advanced understanding of CPT, HCPCS, ICD-10, and billing/payment policies

Ability to identify coding anomalies such as upcoding, unbundling, modifier misuse, and abnormal billing trends

Experience analyzing claims data and translating findings into investigative action

Familiarity with CMS, state regulations, HIPAA, and compliance requirements

Proven ability to manage workloads, coach staff, and collaborate with Compliance, Legal, and Medical teams

Strong written and verbal communication skills, including executive-level reporting

Preferred

SIU, healthcare fraud, or auditing certifications (e.g., CPC, CFE, AHFI)

Benefits

Medical

Vision

Dental

Paid time off

401k

Company

MCMC Services, LLC

MCMC’s Independent Peer Review program compliments your appeal, claims, prior-auth, utilization, and case management programs by providing the comprehensive physician expertise and driven service delivery you need to meet industry and regulatory standards for medical review.

Founded in 1988