Humera - Administrative and Professional Staffing

Review Coordinator I

Minnetonka, MN, United States
Contact For Rate
Sep 24, 2017
Sep 30, 2017
Job Type
Employment Status
Full Time
Humera is seeking a Review Coordinator I for a client based in Minnetonka, MN. This is a contract to hire opportunity.
The Review Coordinator is responsible for coordinating all intake functions into the Utilization Management and Clinical Appeals Department in accordance with all department policies, regulatory and accreditation requirements. It triages, and appropriately processes all information received by the Utilization Management and Clinical Appeals Department.
This is a critical role, as downstream activities, such as pre-service authorization, case management and appeals depend upon the timely, accurate processing of information to perform their job functions and ensure regulatory and accreditation standards are met.
In addition, it researches and resolves provider and/or member questions and issues while maintaining a positive provider and/or member relationship. Thorough knowledge of product information and utilization management and clinical appeals processes are essential for this role.
Process Initiation - 40%

  • Processes all incoming calls, faxes, letters, and email communications using various software applications.
  • Researches and reviews all incoming requests for appropriateness against requirements.
  • Distributes, as appropriate, and redirects to other departments as necessary.
  • Identifies and communicates trends to leadership.
  • Responsible for coordination of resources to resolve provider and member concerns.
  • Provides overview of review process and expected turn around time information to providers if requested.
  • Distributes cases and reviews based on department developed criteria.
  • Educates customers to prevent service problems for members and/or providers.
  • Initiates requests of Utilization Management and Clinical Appeals (to include, but not limited to, admissions, referrals, prior authorizations, retro reviews, concurrent reviews and appeals cases) in CCMS within 24 hours of written notification/requests.
Process Administration - 20%

  • Proficiency in and knowledge of notification, prior authorization, case management, and clinical appeals requirements.
  • Identifies and communicates to department leadership opportunities for improvement and/or enhancements in provider and/or member relationships. [Including but not limited to trends and possible problems in referrals, prior authorization, notification, utilization management, and clinical appeals processes.]
  • Documents pertinent information in appropriate electronic system.
  • Identifies processing errors, misdirected information, other issues, accurately assessing the cause of the problems. Brings trends to leadership.
  • Applies and processes notification requests based on department standards, specific group requirements, and product requirements.
Projects/Team Accountabilities - 20%

  • Completes projects and assignments as directed.
  • Participates in committees and/or projects as assigned.
  • Takes accountability for attending team meetings, 1:1 meetings and performance review of daily work.
Data Systems - 10%

  • Demonstrates proficiency in and knowledge of required electronic systems (including but not limited to Iset, Qstar, CCMS, MN-ITS, KN, KL, and Right fax) when processing notifications, referrals, and prior authorizations.
Policy and Procedures - 10%

  • Assists with development of new or revisions of existing work flows and or Standard Operating Procedures to assure accuracy.
  • Completes policy reviews and trainings in a timely manner to ensure accuracy in process and that compliance measures are met.
  • Complies with all department policies and regulatory and accreditation requirements.

  • Education Level: Associates Degree preferred.
  • Years of experience required: A minimum of 6 months to 1 year.

Specific types of experience required:

  • One year experience in the health care industry.
  • Knowledge and understanding of medical terminology, and coding experience.
  • 1 year managed care and/or health insurance experience.
  • Computer literate.

  • Proficient in investigation and problem solving activities
  • Strong verbal and written communication skills
  • Critical thinking
  • Attention to detail and accuracy
  • Ability to multi-task
  • Administrative support
  • Strong organization skills
  • Customer service - both internal and external
  • Strong interpersonal skills
  • Flexibility in handling changes in work assignments and environment
  • Ability to use Word and Excel at an intermediate level

8:00 am - 5:00 pm Monday - Friday

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