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
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