Clinical Audit Coordinator

Job Description

Job Description

POSITION SUMMARY

The Clinical Audit Coordinator, assisting and informing the Manager of any barriers that may preventing tasks from being completed in a timely and efficient manner.

Individual must be able to execute effective communications verbally and in writing, maintain patient confidentiality, and promote departmental and organizational goals.

RESPONSIBILITIES-DUTIES

• Monitors timeliness of the deferral process for all authorization referral requests and assists with acquiring additional information, including demographic and medical information
• Responsible for initial notification of the deferred status to the provider within 24 hours, and written notification to the member and provider with 72 hour of delay
• Responsible for initial notification of the denied status to the provider within 24 hours, and written notification to the member and provider
• Responsible for maintaining original copies of all deferred requests for submission for medical review after additional information is submitted
• Assist with denial process for all authorization referral requests that have been denied by the Medical Director, including attachment of denials in Ezcap
• PCP notification of patient admissions and discharges
• Manage the Audit Manager application for UM issues per P&P
• Runs applicable reports for the department utilizing database system (Approvals, Denials, Carve-Outs and Deferrals.)
• Manage the claims reports in a timely manner
• Communicates with delegation oversight from the healthplan to conduct the audits and help with the requirements of the health plan
• Works on the Corrective Action Plan for the health plans and actively communicating with the various departments on the audit findings
• Must be familiar with the contents of AMM Policy and Procedures and laws and regulations relating to Coordinators
• Performs other duties as directed by Manager

EDUCATION AND EXPERIENCE REQUIREMENTS

• Two to Three years related experience and / or training; or equivalent combination of education and experience preferred
• High school diploma or GED, bachelor’s degree preferred.
• Must be able to communicate both orally and in writing.
• Ability to apply common sense, to read and comprehend simple instructions to carry out detailed written and / or oral instructions
• Must be able to efficiently prioritize multiple high priority tasks
• Must have the ability to work independently and be organized with minimal supervision
• Must maintain strict confidentiality of all patient information and IPA business
30+ days ago