Urgently required | Clinical Co-Ordinator | Work from Office Only

Job Responsibilities (but not limited to):

• Receives inbound calls, faxes, emails, and mail to initiate an appeal, grievance, or prior authorization request.
• Makes outbound calls to obtain additional information pertaining to an appeal, grievance, DMR, or prior authorization request.
• Collects, organizes, and tracks information received from a variety of resources to facilitate and expedite the processing of requests.
• Generates applicable letters for members and providers in accordance with accreditation and regulatory standards.
• Assists with business operations in the development of communications (e.g., letters, forms) and configuration within the platforms in compliance with state and federal requirements.
• Assists with compiling statistical data, reporting, and analyses to demonstrate clinical, financial, and operational effectiveness and quality.
• Provides support for internal and external audits and surveys.
• Maintains privacy and confidentiality in all interactions.
• Follows all state and federal regulations applicable to clinical operations and utilization management.
• Stays abreast of new regulations to ensure regulatory compliance applicable to clinical operations.
• Meets established productivity and quality standards.
• This position has the ability to engage in on-call weekend work.
  

Qualifications:

Education and/or Training:

• Bachelors degree in public policy or a healthcare related field is preferred; equivalent work experience in related field is acceptable.

Professional Experience:

• At least 2 years relevant experience within a health plan, managed care organization, or third-party administrator is preferred.
• Experience with appeals and grievances, DMRs, and/or prior authorization processes is preferred.
• Experience with Medicare Advantage plans with knowledge of CMS guidance/regulations is preferred.
• Must have a regard for confidential data and adherence to corporate compliance policy.

Specialized Skills:

• Highly developed oral/written communication skills, self-motivation, and ability to work independently with minimal supervision are necessary.
• Strong organizational skills and attention to detail.
• Must be flexible and able to constantly review and reset priorities, often daily, and to handle multiple tasks/projects simultaneously.
• Team player with a collaborative working style.
• Strong interest in healthcare and technology industries.

Technical Skills:

• Strong PC skills; MS Word, Excel
• Access and Power Point skills preferred