Clinical Review Coordinator

Ignite a new era of impactful health outcomes with data that drives answers, technology that advances performance, and expertise that builds trust. Commence develops human-centered, clinically-relevant, value-based solutions that power more efficient process for better program and patient health.

The Clinical Review Coordinator conducts all mandatory case review and quality assurance activities as stipulated by contracts and maintains the required timeliness and accuracy within the review process. The Clinical Review Coordinator conducts all mandatory case review and quality assurance activities as stipulated by contracts and maintains the required timeliness and accuracy within the review process. The role is remote work, but you must reside in the Las Vegas, NV area.

Maintains responsibility for assuring an efficient case review process through the production system. Identifies and corrects problem areas on a case-by-case and system-wide basis. Interprets and applies coverage and payment policies, standards of care, and utilization review criteria applicable to a specific position. Communicates with and supports physician reviewers by summarizing case facts, preparing case questions, and resolving physician input issues. Informs Medicare beneficiaries, health care providers, and other partners of the activities and responsibilities of the Quality Improvement Organization (QIO). Edits documentation for internal and external dissemination to beneficiaries, providers, and other medical personnel. Protects the confidentiality of patient information through compliance with the Health Insurance Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health Act (HITECH). Performs desktop medical reviews. Attends annual security awareness, rules of conduct, and conflict of interest training. Performs other duties as assigned. Depending on departmental assignment, this position may also have some or all of the following duties: Acts as a neutral liaison for beneficiaries and their representatives. Navigates beneficiaries through the health care system. Provides education, advocacy, resource access, and targeted support to decrease the likelihood of readmission to acute inpatient care. Develops and maintains working relationships with community agencies. Assists beneficiaries with an understanding of their diagnoses. Informs beneficiaries and other interested parties of their rights and responsibilities as patients covered by the Medicare program. Schedules staff for the Medicare Beneficiary Helpline during work hours. Collaborates with internal and external QIO staff on the development and implementation of health care improvement projects.