Essential Functions - Lead Review Coordinator:
Performs prospective, concurrent or retrospective utilization review/medical management for all services and quality of care based on contract, state or URAC requirements. Refers cases that fail to meet criteria to peer reviewer.
Collaborates with team members and other health care professionals to develop, implement and complete quality improvement and special project or corrective action initiatives based on review results. This may include technical writing and coordinating the development of materials to promote and support the initiatives or performing extensive research on requested topics to develop projects.
Serves as liaison with internal and external customers to ensure projects, plans and/or products are completed satisfactorily. Maintains positive relationships with internal and external clients to ensure continued participation.
Serves as a representative of the Company at external client meetings. Serves as a mentor to team members to ensure reviews and appeals are conducted thoroughly and within specified time frames.Documents review and special project results in workflow documentation system, ensuring data is accurate and timely.
Assists in compliance reporting.
Performs miscellaneous duties as assigned.
Requirements - Lead Review Coordinator:
Four year degree in health care or two or three year degree in nursing or related field and/or equivalent training and/or experience
Valid, current and appropriate RN license or certification directly relevant to the type of review performed.
5+ years experience in specific areas as needed/designated by the contract or project
Expert Microsoft Office Software knowledge (Access, Excel, Outlook, PowerPoint, Publisher, Word, etc.); significant experience in focus area of project(s).