Clinical Review Coordinator

Soleo Health is an innovative national provider of complex specialty pharmacy and infusion services, administered in the home or at alternate sites of care. Our goal is to attract and retain the best and brightest as our employees are our greatest asset. Experience the Soleo Health Difference! Soleo’s Core Values: Improve patients’ lives every day Be passionate in everything you do Encourage unlimited ideas and creative thinking Make decisions as if you own the company Do the right thing Have fun!

Soleo Health is seeking a Clinical Review Coordinator to support our Home Infusion Specialty Pharmacy Operations Remotely (USA - Pacific time). Join us in Simplifying Complex Care! RN or LPN license Preferred. The Position: 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 Schedule: Monday-Friday, 8:00a-5:00p Pacific time Full-Time

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