Clinical Review Coordinator

Soleo Health Inc•Frisco, TX

2d•Remote

About The Position

Soleo Health is seeking a Clinical Review Coordinator to support our Specialty Infusion Pharmacy and work Remotely (USA) . Join us in Simplifying Complex Care! Must be able to work 8:30am-5pm Eastern Time Zone Monday-Friday. The Clinical Review Coordinator works closely with all departments to research and provide accurate and timely clinical review on complex, patient cases to ensure that approval is secured and to mitigate risk of technical and clinical denials. The Clinical Review Coordinator attempts to resolve denials by utilizing nationally recognized criteria for appeal submission. Responsibilities include:

Requirements

Bachelor’s degree in healthcare field or 3 years in a qualified position
Excellent communication skills (written, oral, and presentation), excellent customer service and interpersonal skills
Flexible communication style, highly motivated team player with excellent listening skills
Able to handle stress to meet identified program objectives and manages time effectively
Self-starter that takes responsibility, is comfortable with accountability and results oriented
Competent in the use of Word, Excel, and Power Point
Must be able to communicate effectively with all levels of organization within Soleo Health.
Must enthusiastically support Soleo Health’s philosophy and goals.
Must be able to work Remote, 8:30am-5pm Eastern Time Zone Monday-Friday
Must have experience with denial support, clinical reviews, and appeals for Infusions

Nice To Haves

Preferred experience with patients with specialty infusion needs and challenges

Responsibilities

Completes prior authorization reviews in a timely manner through their clinical expertise evaluating patient clinicals and payer clinical criteria to determine if the service meets medical necessity of the payer
Reviews and comprehends patient progress notes, lab reports, infusion summaries, imaging reports, and plan of care. Identifies appropriate medical documentation that satisfies payer medical policy criteria.
Request additional clinical information when needed to render a decision and/or determine next steps
Assists with creation of clinical support packets to be used for the initial prior authorization and/or subsequent appeals
In cases of authorization denials, constructs and documents a succinct and fact-based clinical case to support appeal utilizing appropriate medical necessity criteria and other pertinent clinical facts.
Creates and maintains, a library of clinical support resources to include templates for appeals, journal articles, other reference tools that can be used to support medical necessity. When existing resources are unavailable search for supporting clinical evidence to support appeals.
Provides program support by staying current on the top payer covered services, medical necessity requirements and formulary details. Also, must be proficient in locating payer resources related to medical policies.
Assist with post service insurance denials & appeals
Participates in outcome programs including but not limited to data entry, reporting functions, and patient calls with necessary to complete denial support tasks
Provides inter-departmental training to increase teams’ knowledge for top disease states and specialty drugs, clinical requirements, and prior authorization & appeal best practices