Clinical Quality Assurance Coordinator - Supervisor

Join Our Team at MCMC!

We're excited to announce an opportunity for a Clinical Quality Assurance Coordinator - Supervisor to make an impact and lead with excellence.

In this role, you'll oversee the daily operations of our Quality Assurance Department, ensuring workflows run smoothly and efficiently. You'll provide leadership, guidance, and support to a dedicated team, driving quality standards and operational success.

We're looking for someone who brings expertise, organization, and a passion for quality care. If you thrive in a leadership role and enjoy making processes better, this is your chance to shine!

This position is 100% remote with a schedule of Monday through Friday 9:00am-5:30pm EST.

Ready to take the next step in your career? Apply today and help us deliver excellence in clinical quality assurance!

Responsibilities may include:

• 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.

Qualifications

• 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)

MCMC completes over 100,000 reviews each year for more than 400 clients, including almost all of the nation's largest Health Plans, PBMs, Disability Carriers, TPAs, UR companies, Self-Insured Employers, Taft-Hartley Plans and Government Organizations.

Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, pregnancy, genetic information, disability, status as a protected veteran, or any other protected category under applicable federal, state, and local laws.

MCMC offers a fast-paced team atmosphere with competitive benefits (medical, vision, dental), paid time off, and 401k.