Fort Lauderdale, FL
- Job Level:
$16.00 - $19.00/hr.
Coordinator of Clinical Reviews needed for a direct hire in Fort Lauderdale, FL in the insurance industry. The Coordinator will be responsible for coordinating clinical review requests based on benefits, appropriateness, and use of national criteria.
Our client is a medical management organization, which delivers a portfolio of integrated services. The company is located in Fort Lauderdale, FL and has been in the business for over twenty years. As a motto, their market leadership position is of the utmost importance.
- Take incoming telephone calls from members, providers, hospitals, or primary care physicians.
- Receive Faxed or written referral requests for clinical review.
- The Pre-Certification Coordinator performs triage, process intake information, checks eligibility and coverage, and assesses the caller's 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 revises 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: Bachelor's degree or equivalent work experience in data analysis experience.
Experience & Skills Required
- Ability to safely and successfully perform essential job functions consistent with the ADA, FMLA, and other federal, state, and local standards, including meeting qualitative and/or quantitative productivity standards.
- Ability to maintain reasonably regular, punctual attendance consistent with the ADA, FMLA, other federal, state, and local standards, and company attendance policies and procedures.
- Ability to come to work and work the regular schedule and shift for the position.
- Compliance with all personnel policies and procedures.
- Perform related duties as assigned.
- Ability to work both independently and as part of a team of professionals.
- Excellent analytical and problem-solving skills.
- Knowledge of with various aspects of billing, claims adjudication and claims payment for the network specialties. This should include, but may not be limited to Medical terminology, CPT Coding, ICD Code Sets, and CMS Fee Schedules.