Job Description
Clinical Review Coordinator Location: Southfield, MI Duration: 1 year Description:
Requesting Department: Clinical Review
Position summary:
Perform timely initial clinical review as well as provider appeals of select inpatient, outpatient, ambulatory and ancillary services requiring prior authorization. Demonstrate consistent ability to collect pertinent documentation and conduct medical services review applying appropriate criteria, which may include national standardized criteria, established client policy, benefit certificates and other resources as indicated, while at the same time utilizing sound nursing judgment.
Examples of services requiring clinical review include, but are not limited to: - Medical and surgical procedures requiring clinical review/individual consideration (e.g. bariatric surgery, varicose vein treatment, sleep studies) - Durable medical equipment - Prosthetics and orthotics - Out of network services - Benefit extensions/exceptions (e.g., outpatient physical therapy, pregnancy termination, infertility services) - Potentially cosmetic procedures - Genetic laboratory services - High tech radiology procedures - Other procedures/services, as needed (e.g., unlisted/unidentified procedure codes Education and/or experience:
RN with a current valid Michigan license required
Associates Degree in nursing required, Bachelors Degree in nursing, allied health, business or related field preferred.
Three (3) years of acute patient care with broad clinical background required.
One (1) year utilization review required.
Utilization management experience in a managed care environment preferred.
Discharge planning, case management and/or home care experience preferred.
Knowledge of medical terminology and ICD-9 and CPT coding.
Knowledge of State and Federal HMO regulations, and NCQA and related standards preferred.
Other skills and abilities: - Excellent verbal and written communication skills including negotiating skills required - Excellent interpersonal skills including the ability to work with both internal and external customers and all levels of the organization required. - Excellent organizational skills including the ability to handle multiple projects and timelines required. - Knowledge of Managed care philosophy, policies, and procedures - Knowledge of application of clinical criteria/guidelines for medical necessity, setting/level of care, and concurrent patient management. - Knowledge of Medical Management processes across the continuum of care. - Knowledge of standard medical procedures/practices and their application as well as current trends and developments in medicine and nursing. - Knowledge of current medical practices using alternative care settings and levels of service-home care, skilled nursing facilities, sub-acute, hospice and home infusion. - Knowledge (intermediate) of computers including Microsoft Office (e.g. Word, Excel, etc.) with the ability to access and toggle between various systems and resources required - Knowledge of utilization management policies and procedures preferred - Knowledge of client reimbursement policies preferred