Clinical Review Coordinator

Summary

Commence provides data-driven healthcare solutions that combine technology and clinical expertise to improve care quality and efficiency. The Clinical Review Coordinator conducts case reviews and quality assurance activities, applies healthcare coverage and utilization criteria, supports physician reviewers, communicates with beneficiaries and providers, and performs medical reviews and related quality improvement duties.

Responsibilities

• Maintains responsibility for assuring an efficient case review process through the production system
• Identifies and corrects problem areas on a case-by-case and system-wide basis
• Interprets and applies coverage and payment policies, standards of care, and utilization review criteria applicable to a specific position
• Communicates with and supports physician reviewers by summarizing case facts, preparing case questions, and resolving physician input issues
• Informs Medicare beneficiaries, health care providers, and other partners of the activities and responsibilities of the Quality Improvement Organization (QIO)
• Edits documentation for internal and external dissemination to beneficiaries, providers, and other medical personnel
• Protects the confidentiality of patient information through compliance with the Health Insurance Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health Act (HITECH)
• Performs desktop medical reviews
• Attends annual security awareness, rules of conduct, and conflict of interest training
• Performs other duties as assigned
• Acts as a neutral liaison for beneficiaries and their representatives
• Navigates beneficiaries through the health care system
• Provides education, advocacy, resource access, and targeted support to decrease the likelihood of readmission to acute inpatient care
• Develops and maintains working relationships with community agencies
• Assists beneficiaries with an understanding of their diagnoses
• Informs beneficiaries and other interested parties of their rights and responsibilities as patients covered by the Medicare program
• Schedules staff for the Medicare Beneficiary Helpline during work hours
• Collaborates with internal and external QIO staff on the development and implementation of health care improvement projects

Skills

• Individuals must be detailed oriented and clinically knowledgeable of medical terminology
• Graduation from an accredited school of nursing and current unrestricted licensure as a Registered Nurse (RN) or Licensed Practical Nurse (LPN)
• License must be recognized in the jurisdiction(s) relevant to the work assigned. For example, for a federal contract the license must be issued by a body within the United States
• A degree in a healthcare-related field with a professional clinical background and experience with Medicare QIO
• Quality of care review experience or medical review experience in support of Medicare Administrative Contractor (MAC) or Recovery Audit Contractor (RAC) appeals
• Experience performing pre- and post-pay claims reviews, and utilization reviews may also qualify
• Minimum of two to four years of experience in clinical decision-making relative to Medicare patients
• Ability to organize and coordinate multiple simultaneous tasks in a team environment
• Ability to follow complex written and oral instructions
• Ability to collect data, distinguish relevant material, and exercise sound judgment
• Ability to apply problem-solving skills and maintain objectivity
• Strong computer keyboarding skills
• Ability to work independently with minimal supervision
• Ability to communicate accurately, consistently, timely, clearly, empathetically, respectfully, and effectively with beneficiaries, representatives, and providers, both verbally and in writing

Qualifications

Must Haves

• Individuals must be detailed oriented and clinically knowledgeable of medical terminology
• Graduation from an accredited school of nursing and current unrestricted licensure as a Registered Nurse (RN) or Licensed Practical Nurse (LPN)
• License must be recognized in the jurisdiction(s) relevant to the work assigned. For example, for a federal contract the license must be issued by a body within the United States
• A degree in a healthcare-related field with a professional clinical background and experience with Medicare QIO
• Quality of care review experience or medical review experience in support of Medicare Administrative Contractor (MAC) or Recovery Audit Contractor (RAC) appeals
• Experience performing pre- and post-pay claims reviews, and utilization reviews may also qualify
• Minimum of two to four years of experience in clinical decision-making relative to Medicare patients
• Ability to organize and coordinate multiple simultaneous tasks in a team environment
• Ability to follow complex written and oral instructions
• Ability to collect data, distinguish relevant material, and exercise sound judgment
• Ability to apply problem-solving skills and maintain objectivity
• Strong computer keyboarding skills
• Ability to work independently with minimal supervision
• Ability to communicate accurately, consistently, timely, clearly, empathetically, respectfully, and effectively with beneficiaries, representatives, and providers, both verbally and in writing

Benefits

• Remote work position