Clinical Review Coordinator Jobs

Escalates any customer or timeline issues to management

Associates Degree or equivalent combination of education and/or experience

Conducts an administrative review of Protocol/site review and termination submissions by reading, reviewing, and understanding requirements and all supporting documentation

Two (2) years of experience in an office environment (preferably in a regulated industry)

Must have high level of attention to detail, accuracy and thoroughness; Problem solving skills

Excellent interpersonal skills to work professionally and effectively with others and provide high levels of customer service

5+ years of health plan or pharmacy benefit manager experience, specifically involved in prior authorization review

3-5+ years of management experience

Directly manage, coach, and mentor a team of prior authorization technicians

Manage team to meet target KPIs associated with our operating model

Cross-functional collaboration with other departments including troubleshooting eligibility questions, claims adjudication, and benefit designs

Drive quality provider and member experiences by ensuring policy and procedures are adhered to

Short- and long-term disability benefits

Excellent written and oral communication skills

Demonstrated experience with evaluating medical and health care delivery issues

Strong computer skills to include Microsoft Office proficiency

Medical, dental, vision, life and supplemental insurance plans effective the first day of the month following date of hire

401(k) plan with company match and immediate vesting

Collaborate with physicians, claims operations, prior authorization, utilization management, local market teams and support staff as needed

Solid communication, presentation and writing skills

Solid knowledge of medical claims and medical necessity review processes

Intermediate experience using Microsoft Office applications (Word, Excel (pivot tables), PowerPoint)

Proven solid attention to detail and accuracy, excellent evaluative and analytical skills

2+ years of leadership experience

3-5 years’ minimum experience in Occupational health settings, hospital, and outpatient nursing

Career development with an international company where you can grow the career you dream of.

Free medical coverage for employees* via the Health Investment Plan (HIP) PPO

An excellent retirement savings plan with high employer contribution

Provide subject matter expertise in executing Drug Testing Services across Workplace Solutions broad customer base.

Interpret and report results of Workplace clients consistent with Workplace Solutions written Standard Operating Procedures.

Experience working with computer systems with proficient use of database and other office system programs.

Strong oral and written communication skills and presentation skills.

This position is 100% remote and can be located anywhere nationwide.

Review Summary of Findings (SOF) documentation submitted by Surveyors, ensuring accuracy.

Complete the Company Review Form and present the findings of the survey to the Accreditation Review Committee.

Participate as an active member of the Accreditation Review Committee.

Assist with special projects and other responsibilities relating to the conflicts process, as needed.

Excellent oral and written communication skills.

A minimum of 2 years of experience in conflicts clearance or comparable legal experience.

Conflicts experience in a large law firm preferred.

The responsibilities of this position include, but are not limited to, the following:

Conduct preliminary assessments of new matter conflicts reports. Identify, analyze, categorize and summarize information concerning potential conflicts.

3-5 years of home care experience

Strong knowledge of OASIS and Medicare/Medicaid guidelines

OASIS and or Coding certification preferred

Audits and reviews Medicare/non-Medicare charts to ensure that proper standards are maintained in compliance with Federal and State regulations.

Reviews Outcome Assessment Information Set (OASIS) and visit documentation for errors and inconsistencies related to clinical documentation, including wounds

Applies ICD-10-CM coding rules and regulations to the review process.

Five (5) years of progressively responsible management experience in engineering, project management, or a closely related technical area.

Six (6) years of progressively responsible management experience in engineering, hydrology, or a related technical area.

Minimum Qualifications – Education And Experience

six (6) years of progressively responsible management experience in engineering, hydrology, or a related technical area.

Bachelor's degree in Mechanical Engineering, Construction Management, or a related field

Enforce City of Atlanta Code of Ordinances concerning engineering design requirements.

2+ years of experience in utilization management role

Complete cross-training and maintain knowledge of multiple contracts/clients to support coverage needs across the business.

Perform other duties and responsibilities as required, assigned, or requested

Voluntary Benefits (pet insurance, legal insurance, LTC Insurance, etc.)

More information can be downloaded at: http://uhg.hr/uhgbenefits

1+ years of experience working at a Medicare Certified home health agency

Knowledge of managed care processes.

Organizational skills and ability to meet deadlines and manage multiple priorities.

5 years combine knowledge of healthcare processes.

Verbal and written communication skills to include interfacing with staff across organizational lines plus interfacing with members and providers.

PC experience to include Microsoft Word, Access, and Excel.

Health claims and mainframe system experience.

Requires quality management, risk management, peer review, or grievance review experience

Manage performance and hiring processes of direct reports

Proficient in typing skills and in use of PC-based software programs including Microsoft Word and Excel

Excellent communication skills, both written and verbal

Understand and identify opportunities for process and workflow efficiencies and improvements

Collaborate with internal partners and lead CQR-related projects

Proficient computer skills including Microsoft Office programs and database experience

Remain up to date with the contract requirements

3+ years of experience in a clinical environment as a Registered Nurse

Understanding/knowledge of regulatory standards and their application to various examinations and documents

Experience working in an Electronic Medical Record system

Excellent verbal and written communication skills

Knowledge of managed care, utilization management, and quality management

Analyze medical records and apply medical necessity criteria and benefit plan requirements to determine the appropriateness of benefit requests.

Participate in continuing education and current developments in the fields of medicine and managed care.

2 years of experience in clinical field of practice, health insurance, or other health care related field

3 years of experience in clinical field of practice, health insurance, or other health care related field

Communicate team issues and opportunities for improvement to supervisor/manager;

Quality management, audits, risk management, peer review, grievance review or equivalent experience required

3-5+ years hands-on clinical nursing experience across a variety of specialties and settings required

Strong verbal/written communication and organizational skills

Pay Rate: $45/hr - $52/hr (depending on experience)

Prepares cases on-line using department database per departmental protocols. Case assignments may range from routine to complex in scope.

Presents PQI case review summaries/findings to Medical Director at weekly Case Review Meetings as appropriate.

3+ years of experience working in a government, legal, law enforcement, investigations, health care managed care, and/or health insurance environment

3+ years of clinical medical/surgical experience

Experience training and coaching other team members

Experience with Facets, iDRS, CSP, Macess, or other claims processing systems

Collaborate with a team that is triaging, investigating and medical reviewing instances of health care fraud and/or abusive conduct

Perform clinical review of medical record and claims data for PI cases

3 year of Utilization Review and Case Management experience required, 4 or more years preferred

Provide to the patient representative the Acknowledgement of disclosure ,obtain choices of post acute facilities or service and signature

Perform utilization review to evaluate for appropriate level of care and faxes all insurance reviews timely to prevent denials.

Collaborate with patient/family and interdisciplinary team to assess for appropriate discharge needs.

Place and implement all aspects of referrals to all levels of post acute care in 4 Next.

Online documentation of interaction with patient, family and interdisciplinary team.

Experience with Prior Authorization preferred.

Job Family: Medical and Clinical

Date Posted: Apr 04, 2023

Current unrestricted RN license required.

Ability to comprehend medical policy and criteria to clearly articulate health information strongly preferred.

Primary duties may include, but are not limited to: