Job Description

Summary

The Clinical Utilization Coordinator is responsible for reviewing patient referrals/information to determine if diagnosis and clinical documentation support the use of the prescribed products.  The Clinical Utilization Coordinator responds to requests for services for patients. This position communicates telephonically with sales team, prescribers, other departments, and with patients to ensure all necessary information required to support treatment with prescribed therapy is obtained.  Collaborates with the Clinical Utilization Team regarding admission/authorization decisions based on established policies, procedures, guidelines, and infusion experience.  This position ensures that clinical reviews for prior authorizations requests are completed in a timely fashion to meet contractual requirements and are conducted using nationally recognized and evidence-based standards. Participates in Quality Improvement Projects, performs audits of medical records, and assists in preparation for audits and other regulatory activities as directed. They attend to the patient’s needs with utmost patience, care, compassion, and understanding.

Essential Duties and Responsibilities

include the following. Other duties may be assigned, as necessary.

• Reviews and documents medical necessity for immune globulin, biologics, and other therapies as required for referrals.
• Maintains knowledge of insurance companies’ requirements for authorization.
• Reviews clinical documentation for supporting evidence of prescribed therapy for the patient’s diagnosis per established criteria prior to submission of authorization.
• Demonstrates a high degree of responsibility regarding accuracy and quality of work.  
• Maintains an accurate and up to date filing system for medical necessity and pertinent citations and sources by disease process and specialty in the shared company drive.
• Documents current clinical data on the patient’s profile.
• Reviews denied prior authorizations and appeals when appropriate.
• Works closely with prescribers and their staff to coordinate patient care during the prior authorization process and/or appeals process.
• Research referrals that do not clearly meet established criteria.
• Reviews prior authorizations generated by the Benefits Investigation Specialist or Insurance Verification Specialists
• Utilizes Cover My Meds (CCM) to draft prior authorizations.
• Collaborates with Clinical Utilization Team and other referral teams, such as Intake, Patient Care Coordination, and pharmacy to ensure complete patient care.
• Conducts disease specific clinical assessments, as applicable.
• Promotes patient's independence by establishing patient care goals; teaching patient, friends, and family to understand condition, medications, and self-care skills; answering questions.
• Assures quality of care by adhering to therapeutic standards; measuring health outcomes against patient care goals and standards; making or recommending necessary adjustments; following pharmacy and infusion site philosophies and standards of care set by state board of nursing/pharmacy, state nurse/pharmacy practice act, and other governing agency regulations.
• Monitors RTM and RPM programs and contacts patients enrolled on a routine basis to ensure medical compliance, quality, and outcomes.
• Communicates, when necessary, with treating physicians care team.
• Shares outcomes and monitoring data with Clinical Utilization Team and clinical treatment team.
• Maintains continuity among teams by documenting and communicating actions, irregularities, and continuing needs.
• Maintains patient confidence and protects operations by keeping information confidential.
• Maintains effective working relationships and cooperates with all personnel in the Company.
• Adheres to the Company’s compliance requirements as stated in the policy and procedure manual and all other related policies.
• Performs other compliance duties and responsibilities as assigned.

Qualification Requirements

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Provide the highest level of professionalism, responsiveness, and communication to build and maintain the maximum customer base possible.
• Must possess the ability to multi-task and frequently change direction.
• Must have and maintain a valid driver's license, maintain automobile insurance coverage, and have access to a reliable automobile.

COMPETENCIES

• Analytical - Uses intuition and experience to complement data.
• Problem Solving - Identifies and resolves problems in a timely manner; Gathers and analyzes information skillfully; Develops alternative solutions; Works well in group problem solving situations; Uses reason even when dealing with emotional topics.
• Technical Skills - Strives to continuously build knowledge and skills, Shares expertise with others.
• Is proficient in cloud-based systems of communication and documentation such as Monday.com, MS-teams, etc.
• Customer Service - Manages difficult or emotional customer situations; Responds promptly to customer needs; Solicits customer feedback to improve service; Responds to requests for service and assistance.
• Interpersonal Skills - Focuses on solving conflict, not blaming; Maintains confidentiality; Listens to others without interrupting; Keeps emotions under control; Remains open to others' ideas and tries new things.
• Oral Communication - Speaks clearly and persuasively in positive or negative situations; Listens and gets clarification; Responds well to questions.
• Written Communication - Writes clearly and informatively; Able to read and interpret written information.
• Teamwork - Exhibits objectivity and openness to others' views; Gives and welcomes feedback; Contributes to building a positive team spirit.
• Business Acumen - Conserves organizational resources.
• Diversity - Demonstrates knowledge of EEOC policy; Shows respect and sensitivity for cultural differences; Supports affirmative action and respects diversity.
• Ethics - Treats people with respect; Works with integrity and ethically; Upholds organizational values.
• Organizational Support - Follows policies and procedures; Supports affirmative action and respects diversity.
• Planning/Organizing - Uses time efficiently.
• Professionalism - Approaches others in a tactful manner; Reacts well under pressure; Treats others with respect and consideration, regardless of their status or position; Accepts responsibility for own actions; Follows through on commitments.
• Quality - Demonstrates accuracy and thoroughness; Looks for ways to improve and promote quality; Monitors own work to ensure quality.
• Safety and Security - Observes safety and security procedures; Reports potentially unsafe conditions; Uses equipment and materials properly.
• Adaptability - Able to deal with frequent change, delays, or unexpected events.
• Attendance/Punctuality - Is consistently at work and on time.
• Dependability - Follows instructions, responds to management direction.
• Initiative - Asks for and offers help when needed.

Education and/or Experience

• Associates degree or degree from an accredited nursing school as a Licensed Practical Nurse (LPN) or Patient Care Technician (PCT)
• Licensed Pharmacy Technician from an accredited school and licensed as a certified pharmacy technician.
• Maintains certification as a pharmacy technician from a Board recognized national certification organization, which requires the passing of a national certifying examination in the specialty in which the applicant is seeking certification by the Board
• At least two (2) years specialty pharmacy clinical experience
• Strong organizational skills and a thorough knowledge of computers (Microsoft Office and Windows) are required
• Demonstrated ability to work independently and meet goals
• Clinical Skills, Nursing or Pharmacy Skills, Strong knowledge-base in infusion, experience providing immune globulin or other biologics, Teamwork, Multi-tasking, Listening, Verbal Communication, Health Promotion and Maintenance

Preferred Qualifications

• Previous Medicaid/Medicare experience
• Prior authorization/utilization review experience
• IgCN or IgCP, or similar certifications relating to Ig Infusions

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, climb stairs, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.

The employee frequently lifts and/or moves up to 20 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

This job generally operates in a clerical office setting. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets, and fax machines. While performing the duties of this position, the employee may travel by automobile and be exposed to changing weather conditions.

Comments

This description is intended to describe the essential job functions, the general supplemental functions, and the essential requirements for the performance of this job. It is not an exhaustive list of all duties, responsibilities, and requirements of a person so classified. Other functions may be assigned, and management retains the right to add or change the duties at any time.

NOTICE: Successful completion of a drug screen prior to employment is part of our background process, which includes medical and recreational marijuana.

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By submitting your application, you are confirming that you are legally authorized to work in the United States.

JR# JR241550