[Remote] Clinical Review Coordinator

Note: The job is a remote job and is open to candidates in USA. Commence is a company focused on data-driven solutions to enhance health outcomes and improve care efficiency. They are seeking a Clinical Review Coordinator to manage case reviews and quality assurance activities, ensuring compliance and effective communication with healthcare partners.

Responsibilities

• Conducts all mandatory case review and quality assurance activities as stipulated by contracts and maintains the required timeliness and accuracy within the review process
• 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

• 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
• 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

Company Overview