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.