Coordinator of Clinical Reviews Job at Health System One
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.
Job Overview
Date Posted:
Apr 25, 2023Location:
Fort LauderdaleJob Title:
Coordinator of Clinical ReviewsDepartment:
Utilization ManagementHours:
40h / week
About Health Network One
- Primary industry: Healthcare
- Company size: 250 - 300
- Founded in: 1999
- Phone: 1-800-595-9631
- Location: Fort Lauderdale, FL
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