Clinical Services Coordinator, Advanced

Your Role

The Facility Compliance Review (FCR) team reviews post service prepayment facility claims for contract compliance, industry billing standards, medical necessity and hospital acquired conditions.. The Clinical Services Coordinator, Advanced will report to the Manager, Operations FCR. In this role you will assist the clinical team to ensure a timely review of facility compliance claims, including monitoring queues, assisting with administrative support to the FCR team This will include management of daily inventory, assisting with researching claims, pulling medical records and answering questions sent to the FCR mailbox. The main goal of this team is to support the clinical team to ensure they have what they need in order to complete the medical necessity reviews.

Your Work

In this role, you will:

• Process faxed/phoned in authorizations, UM/CM requests, special processing/case types and/or calls left on voicemail
• Monitor specific queues/workstreams and generates pre-defined reports to identify and resolve common errors
• Handle customer/provider problematic calls
• Check member history for case management triage and research member eligibility/benefits and provider networks
• Assign initial EOA days, or triage to nurses, based on established workflow
• Assists with system letters, requests for information and data entry. Monitors for Medical Records Outstanding (MRO), keeps track to ensure timely receipt and filing of medical records. **Requires occasional visits to the office to collect these medical records.
• Provides administrative/clerical support to the FCR team.
• Acts as a liaison, gather information and track all patients referred to the care management programs
• Work with the Operations Specialist and Senior Manager on projects as assigned.
• Monitor specific queues/workstreams and generates pre-defined reports to identify and resolve common errors.

Your Knowledge and Experience

• Requires a high school diploma or equivalent
• Requires at least 5 years of prior relevant experience
• Requires health insurance/managed care experience
• Requires strong computer navigation skills
• Requires independent motivation and strong work ethic