Care Management Coordinator

Job Description

JOB DETAILS

REQUIREMENTS

• RN license, BSN Preferred
• Minimum 3-5 years’ experience with medical criteria reviews
• Strong knowledge of ICD-10, HCPCS and CPT coding/billing
• Claims auditing experience a plus
• Proficiency with Microsoft Word, Outlook, Excel, SharePoint, and Adobe programs. Ability to learn new systems as technology advances.
• Self motivated, highly organized and detailed oriented as well as problem solving, analytical, verbal and written communication skills are required
• Demonstrate the ability to work in a multi-tasking environment

RESPONSIBILITIES

• Reviews provider submission of medical records for specific services that have been processed through system automation and require documentation to determine if additional payment is warranted.
• Reviews specific medical services during the claims adjudication process against medical policies and medical management guidelines to ensure criteria has been met and provides direction to claims processing area.
• Conducts analysis review of post payment claims against current medical policy and medical management guidelines
• Identifies claims/services that require medical records review retrospectively
• Works with Hospitals and Professional providers to obtain medical records to conduct retrospective reviews
• Reviews medical records for identified claims/services to ensure medical criteria based on policies and guidelines have been met
• Identifies and refers cases in which the plan of care/services are not meeting established criteria to the Medical Directors for further evaluation determination
• Collaborates with appropriate areas of the Company including Care Management, Medical Policy, CFID, Appeals, Clinical Vendor Management and Claims Operations.
• Summarizes and tracks all analyses performed and reports to Management
• Identifies and suggests process improvements or potential process efficiencies based on reviews conducted
• Participates in key business area projects
• Assists with review and maintenance of the Claim Medical Review team’s policies, procedures, checklists and documentation as required.
• Performs other related duties as assigned

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