Clinical Review Coordinator - Appeals

At Commence were the start of a new age of data-centric transformation elevating health outcomes and powering better more efficient process to program and patient health. We combine quality data-driven solutions that fuel answers technology that advances performance and clinical expertise that builds trust to create a more efficient path to quality care.

With human-centered healthcare-relevant and value-based solutions we create new possibilities with data. We provide proof beyond the concept and performance beyond the scope with a focus on efficiencies that transform the lives of those we serve. With a culture driven by purpose straightforward communication and clinical domain expertise Commence cuts straight to better care.

The Clinical Review Coordinator 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.

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.
• 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.

Qualifications:

• 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.

Organizational Fit Considerations:

Schedules may vary and may include weekend and holiday shifts. This position requires established professional relationships with internal personnel at all levels within the company and with beneficiaries representatives providers and other stakeholders.

Education:

• 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. For example for a federal contract the license must be issued by a body within the United States.
• 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.
• This position requires notifying a Livanta HR Manager in writing within five calendar days if there is any status change or disciplinary proceeding relating to any of Employees licenses or certifications including but not limited to (1) restrictions on an employees license or certification (2) changes to the states in which Employee can practice (3) revocation or expiration of any license or certification and (4) any potential or actual disciplinary action against Employee by a certifying or licensing body.

SCA Coverage:

Company is a federal contractor under the McNamara-OHara Service Contract Act (SCA).

The McNamara-OHara Service Contract Act (SCA) covers prime contracts of over $2500 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 localityas determined by the U.S. Department of Labor (DOL) in a wage determination.

The position of Clinical 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 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.

Commence is an equal employment opportunity employer. All personnel processes are merit-based and 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.

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