Infusion Clinical Review Coordinator

Soleo Health Inc•Frisco, TX

18d•$65,000 - $80,000•Remote

About The Position

Soleo Health is seeking a remote Infusion Clinical Review Coordinator to support its Specialty Infusion Pharmacy. The role works closely with departments across the organization to research complex patient cases and provide timely, accurate clinical reviews that help secure approvals and mitigate technical and clinical denials. The coordinator also works to resolve denials by using nationally recognized criteria for appeal submissions. The position reviews prior authorizations and patient clinical documentation against payer criteria, identifies supporting medical records, requests additional information, and prepares clinical support materials for initial authorizations and appeals. It also supports post-service insurance denials, maintains clinical reference resources, tracks payer coverage and medical-necessity requirements, participates in outcome programs, and provides interdepartmental training. The schedule is Monday through Friday, 8:30 a.m. to 5:00 p.m. Mountain or Pacific time.

Requirements

Experience with specialty infusion pharmacy is required.
Experience with denial support, clinical reviews, and appeals for infusions and specialty pharmacy is required.
Bachelor’s degree in a healthcare field or three years of experience in a qualified position.
Excellent written, oral, and presentation communication skills, customer service, and interpersonal skills.
Flexible communication style, strong listening skills, and ability to work as a highly motivated team player.
Ability to handle stress, meet program objectives, and manage time effectively.
Self-starter who takes responsibility, is comfortable with accountability, and is results-oriented.
Competence using Word, Excel, and PowerPoint.
Ability to communicate effectively with all levels of the organization.
Ability to enthusiastically support Soleo Health’s philosophy and goals.
Ability to work remotely Monday through Friday, 8:30 a.m. to 5:00 p.m. Mountain or Pacific time.

Nice To Haves

Medical Assistant, LPN, or RN qualification.

Responsibilities

Complete prior authorization reviews promptly by evaluating patient clinical information and payer criteria to determine whether services meet medical necessity requirements.
Review and understand patient progress notes, lab reports, infusion summaries, imaging reports, and plans of care; identify documentation that meets payer medical policy criteria.
Request additional clinical information when needed to make a decision or determine next steps.
Assist in creating clinical support packets for initial prior authorizations and subsequent appeals.
For authorization denials, construct and document a concise, fact-based clinical case supporting an appeal using appropriate medical-necessity criteria and relevant clinical facts.
Create and maintain clinical support resources, including appeal templates, journal articles, and other reference tools; research supporting clinical evidence when resources are unavailable.
Stay current on top payer-covered services, medical-necessity requirements, and formulary details, and locate payer resources related to medical policies.
Assist with post-service insurance denials and appeals.
Participate in outcome programs, including data entry, reporting, and patient calls as needed to complete denial-support tasks.
Provide interdepartmental training on top disease states, specialty drugs, clinical requirements, and prior-authorization and appeal best practices.