Clinical Review Coordinator

Description: CLINICAL REVIEW COORDINATOR (FULL-TIME) AND CLINICAL REVIEW COORDINATOR (PART-TIME) (CASE MANAGER) Summary/Objective: The Clinical Review Coordinator conducts initial screenings in accordance with policies and quality assurance activities as stipulated by contracts. • Maintains responsibility for assuring adherence to policies based on strictly-defined criteria. • Reviews requests for completeness of information. • Scan medical records for structured clinical data, following a CMS algorithm. • Identifies problem areas on a case-by-case and system-wide basis. • Refers cases that require clinical judgement to licensed clinical staff. The Review Coordinator shall not make medical decisions. • Interprets and applies coverage and payment policies, standards of care, and utilization review criteria based on strict policies. • 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). • Attends annual security awareness, rules of conduct, and conflict of interest training. • Performs other duties as assigned. Depending on departmental assignment, this position may also have some or all of the following duties: • Acts as a neutral liaison for beneficiaries and their representatives. • Develops and maintains working relationships with community agencies. • 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. Requirements: Essential Knowledge: Individuals must be detailed oriented and clinically knowledgeable of medical terminology. Essential Knowledge: Individuals must be detailed oriented and clinically knowledgeable of basic medical terminology. Essential Education: • Preference for a degree in a healthcare-related field with a professional clinical background and experience with Medicare QIO. • Preferred 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 healthcare-related field relative to Medicare patients. Essential Skills: • Ability to organize and coordinate multiple simultaneous tasks in a team environment. • Ability to follow basic 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. Organizational "Fit" Considerations: Schedules may vary and may include weekend and holiday shifts. This position requires professional relationships with internal personnel at all levels within the company and with beneficiaries, representatives, providers, and other stakeholders. REVIEW COORDINATOR (PART-TIME) Additional Considerations SCA Coverage: Company is a federal contractor under the McNamara-O'Hara Service Contract Act (SCA). The McNamara-O'Hara Service Contract Act (SCA) covers prime contracts of over $2,500 entered into by the federal government and the District of Columbia. The principal purpose of the contract is to furnish services in the U.S. through the use of service employees. The definition of "service employee" includes any employee engaged in performing services on a covered contract other than a bona fide executive, administrative, or professional employee who meets the exemption criteria outlined in 29 Code of Federal Regulations (CFR) §541. Under the SCA, covered employers must pay the prevailing wages and benefits in the locality—as determined by the U.S. Department of Labor (DOL) in a wage determination. The position of Review Coordinator (Part-Time) is considered a "service position" and is mapped to the Occupation Code and Title 24550 – Case Manager of the current Wage Determination. For more information on this Occupation Code, please refer to the SCA Directory of Occupations at https://www.dol.gov/whd/regs/compliance/wage/SCADirV5/SCADirectVers5.pdf. Wage Determinations and Employee Rights on Government Contracts are posted in break rooms (or an alternative location where labor law posters are displayed) for employees to review. Livanta LLC is an equal employment opportunity employer. All personnel processes are applied without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, marital status, age, disability, national or ethnic origin, military and veteran status or any other characteristic protected by applicable law. If you need assistance or an accommodation due to a disability, you may contact us at 757-306-4920 or [email protected]. Apply Job!