- Oversees and coordinates preauthorization and / or suspended claims and reviews with the nurse reviewers. Manages the workload to guarantee review activities are performed accurately and timely according to accreditation guidelines.
- Conducts monthly quality assurance audits to ensure accuracy of medical review decisions, timeliness, and reliability by the nurse reviewers.
Applies clinical expertise, HMSA and policy criteria, nationally recognized clinical review criteria, and knowledge of standard practice to determine the appropriateness of preauthorization determinations.
Meets with nurse reviewers to review inconsistencies / discrepancies and to develop corrective action plans as needed. Findings are reported to the Clinical Review unit Supervisor for further action and follow up.
- Develops workflows and assessment tools to ensure accuracy and consistency among review determinations. Assists in the development of policies and procedures in relation to medical review preauthorization activities for HMSA's lines of business.
- Ensures all nurse reviewers are informed of and understand new review activities, policies and procedures, workflows, assessment tools, projects and review criteria.
Trains all new nurse reviewers on review processes, criteria and accreditation guidelines.
- Communicates timely, accurate information, either verbally or in writing using discretion and judgment to the provider, suppliers and others as appropriate.
- Serves as liaison for internal departments as well as external customers such as community providers, suppliers and professional organizations.
- Provides back-up in daily review activities in the event of staff absences or high volume case referrals and preauthorization requests.
- Audits provider and member denial letters to ensure denial, benefit, and appeal language are accurate and consistent. Educates providers and vendors on clinical review determinations, policies, criteria and benefits as needed.
- Coordinates the Inter-Rater Reliability audits for the unit to ensure that medical review decisions are appropriate and consistent.
Inconsistencies / discrepancies are discussed with the Medical Directors to resolve discrepancies. Reviews audit findings and reports to the unit Supervisor to discuss and implement improvements.
- Collaborates with all levels of management as well as with Medical Directors on complex reviews.
- Provides support to the unit Supervisor on special case reviews and projects.
- Performs all other miscellaneous responsibilities and duties as assigned or directed.
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Nurse Coordinator, Clinical Review
Ensures all nurse reviewers are informed of and understand new review activities, policies and procedures, workflows, assessment tools, projects and review criteria. Oversees and coordinates preauthorization and/or suspended claims and reviews with the nurse reviewers. Conducts monthly quality assur...
Nurse Coordinator, Clinical Review
Ensures all nurse reviewers are informed of and understand new review activities, policies and procedures, workflows, assessment tools, projects and review criteria. Oversees and coordinates preauthorization and/or suspended claims and reviews with the nurse reviewers. Conducts monthly quality assur...
Nurse Coordinator, Clinical Review
Ensures all nurse reviewers are informed of and understand new review activities, policies and procedures, workflows, assessment tools, projects and review criteria. Oversees and coordinates preauthorization and/or suspended claims and reviews with the nurse reviewers. Conducts monthly quality assur...
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