[Remote] Clinical Review Coordinator

Note: The job is a remote job and is open to candidates in USA. Commence is a company focused on data-driven solutions to enhance health outcomes and improve care efficiency. They are seeking a Clinical Review Coordinator to manage case reviews and quality assurance activities, ensuring compliance and effective communication with healthcare partners.ResponsibilitiesConducts all mandatory case review and quality assurance activities as stipulated by contracts and maintains the required timeliness and accuracy within the review processMaintains responsibility for assuring an efficient case review process through the production systemIdentifies and corrects problem areas on a case-by-case and system-wide basisInterprets and applies coverage and payment policies, standards of care, and utilization review criteria applicable to a specific positionCommunicates with and supports physician reviewers by summarizing case facts, preparing case questions, and resolving physician input issuesInforms 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 personnelProtects 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 reviewsAttends annual security awareness, rules of conduct, and conflict of interest trainingPerforms other duties as assignedActs as a neutral liaison for beneficiaries and their representativesNavigates beneficiaries through the health care systemProvides education, advocacy, resource access, and targeted support to decrease the likelihood of readmission to acute inpatient careDevelops and maintains working relationships with community agenciesAssists beneficiaries with an understanding of their diagnosesInforms beneficiaries and other interested parties of their rights and responsibilities as patients covered by the Medicare programSchedules staff for the Medicare Beneficiary Helpline during work hoursCollaborates with internal and external QIO staff on the development and implementation of health care improvement projectsSkillsGraduation from an accredited school of nursing and current unrestricted licensure as a Registered Nurse (RN) or Licensed Practical Nurse (LPN)License must be recognized in the jurisdiction(s) relevant to the work assignedA degree in a healthcare-related field with a professional clinical background and experience with Medicare QIOQuality of care review experience or medical review experience in support of Medicare Administrative Contractor (MAC) or Recovery Audit Contractor (RAC) appealsExperience performing pre- and post-pay claims reviews, and utilization reviews may also qualifyMinimum of two to four years of experience in clinical decision-making relative to Medicare patientsAbility to organize and coordinate multiple simultaneous tasks in a team environmentAbility to follow complex written and oral instructionsAbility to collect data, distinguish relevant material, and exercise sound judgmentAbility to apply problem-solving skills and maintain objectivityStrong computer keyboarding skillsAbility to work independently with minimal supervisionAbility to communicate accurately, consistently, timely, clearly, empathetically, respectfully, and effectively with beneficiaries, representatives, and providers, both verbally and in writingCompany OverviewCommence delivers AI-driven healthcare data platform and clinical expertise that supports analytics, decisions, and workflow improvement. It was founded in undefined, and is headquartered in Virginia Beach, Virginia, USA, with a workforce of 501-1000 employees. Its website is https://commence.ai.