Case Coordinator

SUMMARY

The Clinical Quality Assurance Coordinator Lead is responsible to assist in the daily workflow of the department, analyze medical records and handle quality assurance questions on medical necessity, utilization review and review files. This position is required to have a complete understanding of the duties required below and helps provide overall direction and support to the Quality Assurance Department.

ESSENTIAL JOB FUNCTIONS

• Provide overall support to the department and assist in the daily distribution of work and ensure all timelines are met and operations are run in the most effective and efficient way possible.
• Perform quality assurance review of reports, correspondences and addendums or supplemental review.
• Conduct concurrent medical record review using specific indicators and criteria in accordance with company policy and procedures.
• Promote effective and efficient utilization of all clinical resources and make necessary recommendations for improvements to management as needed.
• Utilize resources to achieve expected goal within the required timeframe.
• Communicate with physicians to maintain appropriate patient outcomes.
• Assist in resolution of customer complaints and quality assurance issues as needed.
• Provide insight and direction to management on consultant quality, availability and compliance with all company policies and procedures.
• Promote effective and efficient utilization of clinical resources.
• Participate in the development and implementation of policies and procedures in order to provide advice and guidance.
• Participate in various educational and or training activities as required.
• Perform other duties as assigned

ESSENTIAL LEAD RESPONSIBILITIES

• Carrying out all responsibilities in accordance with the companys standards, policies, and all applicable employment laws.
• In conjunction with management, managing and monitoring workflow and providing support, training, and techniques to assist staff in achieving department daily/weekly/monthly goals and standards.

• Encouraging positive morale, maintaining harmony among staff, and resolving grievances when necessary.
• In conjunction with management, communicating change effectively and supporting those affected by change.
• Evaluating staff performance, providing periodic feedback to staff and reporting any performance concerns and/or recommendations for growth opportunities to management.

MINIMUM REQUIRED QUALIFICATIONS

Education and/or Experience
High school diploma or equivalent required. A minimum of two years clinical or related field experience; or equivalent combination of education and experience preferred. Knowledge of the insurance industry, preferably claims management relative to one or more of the following categories: workers' compensation, no-fault, liability, or disability preferred.

Certificates, Licenses, Registrations
No specific requirements.

ESSENTIAL COMPETENCIES

QUALIFICATIONS

• Must possess a working knowledge of medical legal aspects of medical records and health information principles and/or liability.
• Must be a qualified typist with a minimum of 40 W.P.M.
• Ability to analyze problems involving multiple interrelated causes, gathers information and applies complex concepts or methods to generate an effective solution.
• Must possess complete knowledge of general computer, fax, copier, scanner, and telephone.
• Must be knowledgeable of multiple software programs, including but not limited to Microsoft Word, Excel, and the Internet.
• Ability to follow instructions and respond to upper managements directions accurately.
• Must demonstrate accuracy, thoroughness, and responsibility for quality of work, and ability to take initiative to identify improvements. Look for ways to improve and promote quality and monitors own work to ensure quality is met.
• Must demonstrate exceptional communication skills.
• Must be able to work independently, prioritize work activities and use time efficiently.
• Must be able to maintain confidentiality.
• Must be able to demonstrate and promote a positive team -oriented environment.
• Must be able to stay focused and concentrate under normal or heavy distractions.
• Must be able to work well under pressure and or stressful conditions.
• Must possess the ability to manage and direct change, delays, or unexpected events appropriately.
• Ability to follow all company policies and procedures in effect at time of hire and as they may change or be added from time to time.

LANGUAGE/COMMUNICATION SKILLS

• Ability to read, analyze and interpret common correspondence, medical records, and legal contracts and documents.
• Ability to write clearly and informatively to all required audiences and edit own work for appropriate spelling and grammar.
• Ability to respond appropriately and professionally to all inquiries or complaints from customers, physicians, regulatory agencies, and/or members of the business community.
• Ability to effectively present information one-on-one or in small groups.

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

This position generally consists of:

• Ability to work at a desk or similar office-type furnishings up to 8 hours a day or longer as required by business needs.
• Ability to operate a computer up to 4 hours at a time.
• Ability to travel to different floors of the office or other locations.
• Ability to move throughout the office.
• Occasionally lifting and/or carrying up to 10 lbs.
• Occasionally pushing/pulling up to 25 lbs.
• Occasionally subject to bending, squatting or twisting.