Job TitleCoordinates case review activities consistent with corporate policy and client-specific procedures. Determines the types of review, peer clinical reviewer specialties and selects peer clinical reviewers. Oversees the logging of cases. Verifies peer clinical reviewer credentials and lack of conflict of interest. Corresponds with reviewers regarding availability, expertise, deadline, etc.
Negotiates and assigns peer clinical reviewer fees (as authorized by the Vice President). Ensures that the invitation in URPP is forwarded to, and received by, the peer clinical reviewer in a timely manner. Maintains active dialogs with the client and the peer clinical reviewer while the case is under review. Monitors case due date and takes steps to ensure timely return to the client. Ensures that the peer clinical reviewer's determination is complete and oversees transcription.
Notifies the client and other designated parties of the final determination. Interacts on a daily basis with the Chief Medical Director, as needed, to complete case reviews. Serves as the primary liaison and resource for clients and peer clinical reviewers. Assists in the recruitment of new peer clinical reviewers. Participates in staff and/or client meetings and telephone conferences, as needed.
Actively participates in the orientation and training of new Review Coordinator Assistants. Participates in quality improvement activities, as requested.Holds a post-secondary degree; Has undergone formal training in a health care field; Experience in health insurance, utilization review, quality management and/or managed care Pursues excellence while achieving results within defined parameters Listens effectively and expresses ideas, both verbally and non-verbally, to achieve understanding Demonstrates flexibility and effectiveness with changing tasks, responsibilities and people Maintains stable and effective performance under pressure or demanding challengesMust be able to both speak clearly and hear, as frequent use of the telephone is required Must be able to work under conditions of frequent stress in order to meet deadlines Must have sufficient close-vision capabilities and use of hands in order to perform computer tasks Must be able to sit for extended periods of time