Humera Review Coordinator I in Minnetonka, Minnesota

Review Coordinator I|Minnetonka, MN

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Review Coordinator I

Minnetonka, MN

Humera is seeking multiple Review Coordinator for our client in Minnetonka, MN. The individual's in this role are responsible for coordinating all intake functions into the Utilization Management and Clinical Appeals Department in accordance with all department policies,

regulatory and accreditation requirements. It triages, and appropriately processes all information received by the Utilization Management and Clinical Appeals Department. This is a critical role,

as downstream activities, such as pre-service authorization, case management and appeals depend upon the timely, accurate processing of information to perform their job functions and ensure

regulatory and accreditation standards are met. This is a contract to hire opportunity.

Duties

Process Initiation - 40%

  • Processes all incoming calls, faxes, letters, and email

communications using various software applications.

  • Researches and reviews all incoming requests for

appropriateness against requirements.

  • Distributes, as appropriate, and redirects to other departments

as necessary.

  • Identifies and communicates trends to leadership.

  • Responsible for coordination of resources to resolve provider

and member concerns.

  • Provides overview of review process and expected turn around

time information to providers if requested.

  • Distributes cases and reviews based on department developed

criteria.

  • Educates customers to prevent service problems for members

and/or providers.

  • Initiates requests of Utilization Management and Clinical

Appeals (to include, but not limited to, admissions, referrals,

prior authorizations, retro reviews, concurrent reviews and appeals

cases) in CCMS within 24 hours of written

notification/requests.

Process Administration - 20%

  • Proficiency in and knowledge of notification, prior

authorization, case management, and clinical appeals

requirements.

  • Identifies and communicates to department leadership

opportunities for improvement and/or enhancements in provider

and/or member relationships. (Including but not limited to trends

and possible problems in referrals, prior authorization,

notification, utilization management, and clinical appeals

processes.)

  • Documents pertinent information in appropriate electronic

system.

  • Identifies processing errors, misdirected information, other

issues, accurately assessing the cause of the problems. Brings

trends to leadership.

  • Applies and processes notification requests based on department

standards, specific group requirements, and product

requirements.

Projects/Team Accountabilities - 20%

  • Completes projects and assignments as directed.

  • Participates in committees and/or projects as assigned.

  • Takes accountability for attending team meetings, 1:1 meetings

and performance review of daily work.

Data Systems - 10%

  • Demonstrates proficiency in and knowledge of required

electronic systems (including but not limited to Iset, Qstar, CCMS,

MN-ITS, KN, KL, and Right fax) when processing notifications,

referrals, and prior authorizations.

Policy and Procedures - 10%

  • Assists with development of new or revisions of existing work

flows and or Standard Operating Procedures to assure accuracy.

  • Completes policy reviews and trainings in a timely manner to

ensure accuracy in process and that compliance measures are

met.

  • Complies with all department policies and regulatory and

accreditation requirements.

Qualifications

Experience & Education

  • Associates Degree preferred.

  • A minimum of 6 months to 1 year of experience.

Specific Skills

  • One year experience in the health care industry.

  • Knowledge and understanding of medical terminology, and coding experience.

  • 1 year managed care and/or health insurance experience.

  • Computer literate

Skills and Abilities

  • Proficient in investigation and problem solving activities

  • Strong verbal and written communication skills

  • Critical thinking

  • Attention to detail and accuracy

  • Ability to multi-task

  • Administrative support

  • Strong organization skills

  • Customer service – both internal and external

  • Strong interpersonal skills

  • Flexibility in handling changes in work assignments and environment

  • Ability to use Word and Excel at an intermediate level

Post Date: 09.19.2018

Salary: Contact for Rate

Shift: 1st