Clinical Coordination Manager
7 days ago
Job Summary:
Clinical Utilization Specialists play a crucial role in ensuring that patients receive the necessary medical treatments and services. As a Clinical Utilization Specialist at CSI Pharmacy, you will be responsible for reviewing patient referrals and information to determine if diagnosis and clinical documentation support the use of prescribed products.
Key Responsibilities:
- Review and Document Medical Necessity: Review and document medical necessity for immune globulin, biologics, and other therapies as required for referrals.
- Maintain Knowledge of Insurance Requirements: Maintain knowledge of insurance companies' requirements for authorization.
- Review Clinical Documentation: Review clinical documentation for supporting evidence of prescribed therapy for the patient's diagnosis per established criteria prior to submission of authorization.
- Ensure Quality and Accuracy: Demonstrate a high degree of responsibility regarding accuracy and quality of work.
- Maintain Filing System: Maintain an accurate and up-to-date filing system for medical necessity and pertinent citations and sources by disease process and specialty in the shared company drive.
- Document Patient Information: Document current clinical data on the patient's profile.
- Review Denied Prior Authorizations: Review denied prior authorizations and appeals when appropriate.
- Coordinate Patient Care: Work closely with prescribers and their staff to coordinate patient care during the prior authorization process and/or appeals process.
- Research Referrals: Research referrals that do not clearly meet established criteria.
- Review Prior Authorizations: Review prior authorizations generated by the Benefits Investigation Specialist or Insurance Verification Specialists.
- Utilize Clinical Tools: Utilize Cover My Meds (CCM) to draft prior authorizations.
- Collaborate with Clinical Teams: Collaborate with Clinical Utilization Team and other referral teams, such as Intake, Patient Care Coordination, and pharmacy to ensure complete patient care.
- Conduct Disease-Specific Assessments: Conduct disease-specific clinical assessments, as applicable.
- Promote Patient Independence: Promote patient's independence by establishing patient care goals; teaching patient, friends, and family to understand condition, medications, and self-care skills; answering questions.
- Ensure Quality of Care: Assure quality of care by adhering to therapeutic standards; measuring health outcomes against patient care goals and standards; making or recommending necessary adjustments; following pharmacy and infusion site philosophies and standards of care set by state board of nursing/pharmacy, state nurse/pharmacy practice act, and other governing agency regulations.
- Monitor Patient Outcomes: Monitor RTM and RPM programs and contacts patients enrolled on a routine basis to ensure medical compliance, quality, and outcomes.
- Communicate with Healthcare Teams: Communicate, when necessary, with treating physicians care team.
- Share Outcomes and Monitoring Data: Shares outcomes and monitoring data with Clinical Utilization Team and clinical treatment team.
- Maintain Continuity: Maintains continuity among teams by documenting and communicating actions, irregularities, and continuing needs.
- Protect Patient Confidentiality: Maintains patient confidence and protects operations by keeping information confidential.
- Support Team Collaboration: Maintains effective working relationships and cooperates with all personnel in the Company.
- Adhere to Compliance Requirements: Adheres to the Company's compliance requirements as stated in the policy and procedure manual and all other related policies.
Qualification Requirements:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Professionalism and Responsiveness: Provide the highest level of professionalism, responsiveness, and communication to build and maintain the maximum customer base possible.
- Multi-Tasking and Adaptability: Must possess the ability to multi-task and frequently change direction.
- Valid Driver's License: Must have and maintain a valid driver's license, maintain automobile insurance coverage, and have access to a reliable automobile.
Preferred Qualifications:
- Medicaid/Medicare Experience: Previous Medicaid/Medicare experience.
- Prior Authorization/Utilization Review Experience: Prior authorization/utilization review experience.
- Certifications: IgCN or IgCP, or similar certifications relating to Ig Infusions.
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