Clinical Review Coordinator

Description At Commence, we’re the start of a new age of data‑centric transformation, elevating health outcomes and powering better, more efficient processes to program and patient health. We combine quality data‑driven solutions that fuel answers, technology that advances performance, and clinical expertise that builds trust to create a more efficient path to quality care. With human‑centered, healthcare‑relevant, and value‑based solutions, we create new possibilities with data. We provide proof beyond the concept and performance beyond the scope with a focus on efficiencies that transform the lives of those we serve. With a culture driven by purpose, straightforward communication and clinical domain expertise, Commence cuts straight to better care. Job Type Full‑time Requirements Maintains responsibility for assuring an efficient case review process through the production system. Identifies and corrects problem areas on a case‑by‑case and system‑wide basis. Interprets and applies coverage and payment policies, standards of care, and utilization review criteria applicable to a specific position. Communicates with and supports physician reviewers by summarizing case facts, preparing case questions, and resolving physician input issues. Informs Medicare beneficiaries, health care providers, and other partners of the activities and responsibilities of the Quality Improvement Organization (QIO). Edits documentation for internal and external dissemination to beneficiaries, providers, and other medical personnel. Protects the confidentiality of patient information through compliance with HIPAA and HITECH. Performs desktop medical reviews. Attends annual security awareness, rules of conduct, and conflict of interest training. Performs other duties as assigned. Additional Duties (if applicable) Acts as a neutral liaison for beneficiaries and their representatives. Navigates beneficiaries through the health care system. Provides education, advocacy, resource access, and targeted support to decrease the likelihood of readmission to acute inpatient care. Develops and maintains working relationships with community agencies. Assists beneficiaries with an understanding of their diagnoses. Informs beneficiaries and other interested parties of their rights and responsibilities as patients covered by the Medicare program. Schedules staff for the Medicare Beneficiary Helpline during work hours. Collaborates with internal and external QIO staff on the development and implementation of health care improvement projects. Essential Knowledge Individuals must be detail oriented and clinically knowledgeable of medical terminology. Essential Education Graduation from an accredited school of nursing and current unrestricted licensure as a Registered Nurse (RN) or Licensed Practical Nurse (LPN). License must be recognized in the jurisdiction(s) relevant to the work assigned. For example, for a federal contract the license must be issued by a body within the United States. A degree in a healthcare‑related field with a professional clinical background and experience with Medicare QIO. Quality of care review experience or medical review experience in support of Medicare Administrative Contractor (MAC) or Recovery Audit Contractor (RAC) appeals. Experience performing pre‑ and post‑pay claims reviews, and utilization reviews may also qualify. Minimum of two to four years of experience in clinical decision‑making relative to Medicare patients. This position requires notifying a Livanta HR Manager in writing within five calendar days if there is any status change or disciplinary proceeding relating to any of Employee’s licenses or certifications, including restrictions on an employee’s license or certification, changes to the states in which Employee can practice, revocation or expiration of any license or certification, and any potential or actual disciplinary action against Employee by a certifying or licensing body. Essential Skills Ability to organize and coordinate multiple simultaneous tasks in a team environment. Ability to follow complex written and oral instructions. Ability to collect data, distinguish relevant material, and exercise sound judgment. Ability to apply problem‑solving skills and maintain objectivity. Strong computer keyboarding skills. Ability to work independently with minimal supervision. Ability to communicate accurately, consistently, timely, clearly, empathetically, respectfully, and effectively with beneficiaries, representatives, and providers, both verbally and in writing. Additional Considerations Company is a federal contractor under the McNamara‑O'Hara Service Contract Act (SCA). The SCA covers prime contracts of over $2,500 entered into by the federal government and the District of Columbia. The position of Clinical Review Coordinator (Part‑Time) is considered a “service position” and is mapped to the Occupation Code and Title 24550 – Case Manager of the current Wage Determination. For more information on this Occupation Code, refer to the SCA Directory of Occupations. Organizational Fit Considerations Schedules may vary and may include weekend and holiday shifts. This position requires established, professional relationships with internal personnel at all levels within the company and with beneficiaries, representatives, providers, and other stakeholders. Equal Employment Opportunity Statement Commence.AI is committed to providing equal employment opportunities to all applicants, including individuals with disabilities. Salary $83,200 #J-18808-Ljbffr Commence