Role and Responsibilities:

• Coordinates case review activities consistent with corporate policy and client-specific procedures
  • Determines the types of review, peer clinical reviewer specialties and selects peer clinical reviewers
  • Oversees the logging of cases
    • Verifies peer clinical reviewer credentials and lack of conflict of interest
    • Corresponds with reviewers regarding availability, expertise, deadline, etc.
  • Negotiates and assigns peer clinical reviewer fees (as authorized by the Vice President)
  • Ensures that the invitation in URPP is forwarded to, and received by, the peer clinical reviewer in a timely manner
  • Maintains active dialogs with the client and the peer clinical reviewer while the case is under review
  • Monitors case due date and takes steps to ensure timely return to the client
  • Ensures that the peer clinical reviewer’s determination is complete and oversees transcription
  • Notifies the client and other designated parties of the final determination
• Interacts on a daily basis with the Chief Medical Director, as needed, to complete case reviews
• Serves as the primary liaison and resource for clients and peer clinical reviewers
• Assists in the recruitment of new peer clinical reviewers
• Participates in staff and/or client meetings and telephone conferences, as needed
• Actively participates in the orientation and training of new Review Coordinator Assistants
• Participates in quality improvement activities, as requested

Education, Experience and Professional Competencies:

• Holds a post-secondary degree;
• Has undergone formal training in a health care field;
• Experience in health insurance, utilization review, quality management and/or managed care
• Pursues excellence while achieving results within defined parameters
• Listens effectively and expresses ideas, both verbally and non-verbally, to achieve understanding
• Demonstrates flexibility and effectiveness with changing tasks, responsibilities and people
• Maintains stable and effective performance under pressure or demanding challenges

Physical Demands:

• Must be able to both speak clearly and hear, as frequent use of the telephone is required
• Must be able to work under conditions of frequent stress in order to meet deadlines
• Must have sufficient close-vision capabilities and use of hands in order to perform computer tasks
• Must be able to sit for extended periods of time