Humera - Administrative and Professional Staffing

Review Coordinator II

7 days left

Location
Minnetonka, MN, United States
Salary
Contact For Rate
Posted
Aug 11, 2018
Closes
Aug 23, 2018
Job Type
Employee
Employment Status
Full Time
Humera is seeking a Review Coordinator for our client, a major health care provider in Minnetonka. The Review Coordinator II is responsible for coordinating and supporting all intake functions into the Utilization Management and Clinical Appeals Department. This is a contract position.Duties

Process Administration (45%)
  • Proficiency in and knowledge of notification, prior authorization, case management, and clinical appeals process requirements.
  • Researches, investigates, and compiles claims history, Qstar and/or Iset notes, historical files, certificate of coverage, and other materials required for review.
  • Gathers appropriate information for clinical staff, including pharmacists. Requests medical records from providers, monitors status, and follows up with providers as needed per department protocols. Compiles medical records and coordinates next steps with clinical reviewer.
  • Utilizes the Medical Affairs Department to clarify coverage and utilization management policies.
  • Identifies and communicates to department leadership opportunities for improvements and/or enhancements.
  • Performs care availability searches. Authorizes in-network benefits with out-of-network providers when appropriate and sends authorization letters.
  • Manages non-clinical authorizations and non-clinical DTRs per department criteria. Prepares and presents information to medical director per department protocols. Prepares and generates associated letters as required.
  • Documents pertinent information in appropriate software systems.
  • Identifies processing errors, misdirected information, other issues, accurately assessing the cause of the problems. Brings trends to leadership.
Process Initiation (15%)
  • Processes incoming calls, faxes, letters, and email communications using various software applications.
  • Manages initial intake of prior authorization, retro review, clinical appeal requests and concurrent review requests from providers.
  • Researches all incoming requests for appropriateness against requirements.
  • Distributes or redirects information to nurse reviewers as appropriate and other departments as necessary.
  • Communicates trends to leadership
  • Responsible for first line contact and 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.
  • May be a resource to other team members
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.
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.
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.

Requirements

  • Associates Degree preferred.
  • Years of experience required: 2 years
  • 1+ years experience in the health care industry
  • Knowledge and understanding of medical terminology and coding
  • Computer literate
  • Investigation and problem solving skills
  • Strong verbal and written communication skills
  • Critical thinking
  • Attention to detail and accuracy
  • Administrative support
  • Strong organizational skills
  • Customer service - both internal and external
  • Strong interpersonal skills
  • Flexibility in handling changes in work assignments and environment

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