Clinical Review Coordinator

1 month ago


Ontario California, United States Prime Healthcare Management Inc Full time
Job Summary

The Clinical Review Coordinator will play a crucial role in coordinating the utilization review and appeals process as part of the denial management initiatives. This position will serve as a liaison and own the coordination with other UR techs in the team, while being responsible for coordinating phone calls, data entry, mailing/faxing appeals and tracking data from various insurance providers and health plans regarding authorization, expedited reviews and appeals.

Key Responsibilities
  • Document and track all communication attempts with insurance providers and health plans and scan all related correspondence to the respective EMR/ tracking tool.
  • Follow up on all denials while working closely with the Corporate/Facility Utilization review teams, Business Office and Case Managers.
  • Coordinate the work to maintain integrity of tracking government review audits (RAC, MAC, CERT, ADR, Pre/Post Probes, QIO/Medicaid) and other payer audits as assigned.
  • Function as an SME to support the UR tech team and remote counter parts with the specific processes as applicable.
  • Support the department needs for Release of Information through faxing and mailing, discharge coordination or other duties as assigned.
Requirements
  • Bachelor's degree or four years of relevant experience required.
  • Microsoft office proficiency.
  • Good communication skills.
  • Completion of a medical terminology course; preferred.
  • Knowledge of HIPAA regulations preferred.


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