Utilization Review Coordinator jobs in Lawrence, KS

Company: KFMC Health Improvement Partners
Position: Review Coordinator
Job Classification: Exempt, Full-time
Work Schedule: Mutually Determined
Reports to: Director of Clinical Care Review and Quality Improvement
Location: Topeka, KS (on-site)

KFMC Health Improvement Partners (KFMC) is a not-for-profit organization focused on improving healthcare quality.  We inspire meaningful change and sustained high performance within the organizations and communities where we work. We’re a diverse team of multi-disciplinary professionals all focused on the same vision…best health outcomes for everyone. We believe our team members do their best work when they love what they do, and we have created an environment that fosters creativity, excellence and fun! We prioritize and value the things that are important to us, both as people and as professionals, including flexibility and a family-friendly culture. KFMC is currently seeking a Review Specialist. As a member of the Clinical Care Review Team, this  position will support our clinical care review activities in Oklahoma and Kansas.   The Review Coordinator is responsible for interacting with our panel of peer reviewers (PRs), including physicians, mid-levels and other types of direct care providers.  The Review Coordinator  is responsible for scheduling PRs for our various review programs, recruiting providers to serve as reviewers, maintaining PR recruitment files, conducting PR internal quality control (IQC) activities, typing and proofing determination letters, and coordinating the distribution of medical records to reviewers to ensure reviews are completed within provided timelines.  The ideal candidate will have experience working directly with physicians and other care providers in a provider office or other clinical setting; at least two years of prior experience in a healthcare setting is required.    Business or vocational graduate in a health-related course of study is also required; Medical Assistant is preferred.

Primary Accountability:
This position is responsible for managing the completion of reviews and processing of selected cases and/or special requests, timely, accurately and according to KFMC contract requirements. Organizes retrospective clinical reviews using established guidelines and processes. Communicates with physicians, facility staff, agency staff and others to process cases referred for review, ands capture data related to utilization, quality and cost. Requests, receives, organizes, and coordinates the distribution of medical records for review. Works with both paper-based and electronic medical records. This position works in collaboration with internal staff members and/or departments as well as external sources; the position is expected to function independently, as well as collaboratively.

Major Duties:

• Manages the completion of review functions based on established procedures and contract requirements.
• Provides consultation and advice to executive teams and management teams during clinical review, to revise and create the organization’s operating practices and policies.
• Prepare and maintain Peer Reviewer (PR) credentialing files including certification and recertification.
• Facilitate PR recruitment.
• Responsible for PR scheduling, PR reimbursement, and for being the contact person for all PR inquiries and activity.
• Acts as the liaison for providers submitting medical records and directs distribution and retention of medical records for all review activity.
• Responsible for monitoring and reporting various case review activities.
• Responsible for performing financial adjustments within the State’s Medicaid Management Information System (MMIS).
• Collaborates with the Medical Director, Physician and Peer Reviewer, as necessary.
• Provide education to clients and providers related to review activities as needed.
• Participation in Internal Quality Control activities.
• Serve as a resource person for external inquiries received from hospital personnel, patients, physicians, federal and state government officials, and private clients related to job assignments.
• Report information, questions or complaints from outside customers that cannot be resolved to the Case Review Manager/Director.
• Assist in development, revision and implementation of KFMC programs, policies and procedures.
• Keep team members informed of all activities within area of responsibility.
• Participate in case review improvement where customer satisfaction and efficiency can be improved.
• Keep current on contract requirements and review procedures. Must be able to adapt to change easily and apply the information learned to his/her job as a Sr. Review Coordinator.
• Assist Case Review Manager/Director with developing and updating procedures as necessary.
• Assists with resolution of project delays.
• Responsible for project scheduling, attending all project meetings, and project completion documentation.
• Assist in fiscal responsibility of the project.
• Assist in project execution to ensure deadlines, scope, and budget costs are met.
• Keep informed of industry changes, trends, and best practices and assess the potential impact of those changes on company practices.
• Assist in ensuring the company’s compliance with regulatory requirements, policies are in place, and that procedures are documented, implemented, and communicated to all individuals impacted.

Qualifications:

• Graduate of an accredited college or university in healthcare or project management related field, or demonstrated commensurate experience is required. Commensurate experience may be demonstrated by project/contract management certifications.
• Medical Assistant preferred. Significant training and experience in a health-related field may be substituted for educational requirements.
• Minimum of (3-5) three to five years’ experience in a health-related field.
• Experience interacting with health care providers is required.
• Customer Service experience is preferred.
• Knowledge of medical terminology.
• Ability to read handwritten medical records.
• Intermediate to advanced computer skills is required with typing skills fo 50 wpm.
• Strong and effective written and verbal communication skills.
• Interpersonal skills to collaborate effectively with internal and external customers.
• Strong attention to accuracy and detail required.
• Ability to identify and initiate process improvements.
• Ability to communicate effectively and express comments and opinions clearly and concisely in a diplomatic manner.
• Strong organizational skills and the ability to coordinate multiple projects.
• Professional attitude and the ability to maintain confidentiality.
• Demonstrated ability to work independently and as a team member.
• Familiarity with the health care delivery system and experience in working with health care providers and/or the public.
• Must have the ability to appraise any situation and exercise good judgment.
• Ability to work independently and make decisions based on contract policies and procedures.
• Ability to demonstrate proficiency in planning, organizing, and problem-solving techniques.
• Must be able to interact with KFMC staff, physicians, hospital personnel, a variety of professionals, and the public in a tactful, diplomatic manner to establish rapport and win confidence.
• Familiarity with various computer software applications (i.e., Microsoft Office).
• Represent KFMC professionally in appearance and conduct.
• Case Review staff with specific credentials required by their position description will provide a copy of their current credential status, and subsequent renewals to the Case Review Manager and Human Resources. Case Review staff are required to report an adverse change in the status of a required credential within three business days of receiving notice from the credentialing authority. Staff may submit a notice of adverse change in a credential by any format and will submit a plan to bring the credential into compliance with the requirement of their Position Description.

Physical Demands:

• Ability to sit for extended periods of time.
• Ability to read computer screens and mail.
• Ability to unpack and move supplies up to 50 lbs.
• Ability to drive an automobile.
• Ability to travel as directed by position requirements.

Work Environment:

• Professional and deadline-oriented environment in an office setting.
• Interaction with internal and external customers.

Additional Duties:
Additional duties and responsibilities may be added to this job description at any time. The job description does not state or imply that these are the only activities to be performed by the employee(s) holding this position. Employees are required to follow any other job-related instructions and to perform any other job-related responsibilities as requested by their supervisor.