Coordinator of Clinical Reviews

  • Utilization Management
  • Fort Lauderdale
  • 1 month ago
  • 1 available

Job Description

This position is responsible for coordinating clinical review requests based on benefits, appropriate-ness, and use of national criteria.

Essential Functions & Responsibilities

  • Take incoming telephone calls from members, providers, hospitals, or primary care physicians.
  • Receive Faxed or written referral requests for clinical review.
  • Coordinator performs triage, process intake information, checks eligibility and coverage, and assesses the callers needs; everything from a simple referral for a diagnostic assessment to a need for immediate action, referral to case management, or Medical Director. This position does not make clinical review decisions.
  • Provides assistance to process Level 3 Clinical Medical Review with collecting clinical documentation to support appropriate use of national criteria.
  • Ensures the organization revise all clinical information for Level 3 Medical Director reviews.
  • Ensures compliance with and/or adheres to Company HIPAA policies and procedures.
  • Ensures the integrity of data entered into Company systems and/or database.
  • Ensures Program Integrity for Fraud/Abuse and Exclusions.

Required Education and Experience

  • Two-year College or technical school; or six months to one year related experience and/or training; or equivalent combination of education and experience.
  • Previous experience in Pre-Certification a plus.