Job Purpose:

•       To assist in Business Services workflow by opening and distributing of incoming mail, entering hard copy claims, and other duties as assigned.

Roles and Responsibilities:

•       Data entry of confidential medical claim information

•       Sort and distribute daily incoming mail following JVHL Mail Procedure

•       Management of daily and monthly hard copy claim distribution and inventory

•       Prepare and process outgoing mail

•       Assist with email communications as needed

•       Update job knowledge by participation in education opportunities

•       Follow all JVHL compliance policy and employee regulations

•       Deliver timely and effective departmental support utilizing a range of resources

•       Participate in claim appeal inquiries and follow up

•       Other duties as assigned

Education/Qualifications:

•       High School diploma with 0-2 years of experience in the field or in a related area

•       Proficient in computer skills including Microsoft Word, Excel, PowerPoint, and Outlook

•       Excellent verbal and written communication skills

•       Typing at 50-60 wpm

Required Skills:

•       Ability to follow instruction

•       Ability to adapt to varying work flow

•       Attention to detail

•       Ability to work independently

Job Purpose: The Clinical Nurse Coordinator is a state licensed Registered Nurse that provides management oversight in implementing the Utilization Management (UM) department functions, including prior authorization decisions and retrospective reviews for nonpatient laboratory services.

Roles and Responsibilities:

• Provide leadership in the design and implementation of UM policies, processes, and procedures
• Ensure quality of UM services and that contractual and regulatory requirements remain compliant through daily supervision of assigned utilization management team and required reporting.
• Maintain knowledge of regulatory and accreditation agencies and related delegated requirements pertinent to case management, such as BCN Medical Policy and NCQA
• Oversee the review of quality concerns identified through the QI process and the implementation and monitoring of corrective action plans
• Conducts clinical reviews of authorized approval and denial recommendations from JVHL Prior Authorization Specialist for prior and retro authorizations
• Coordinates as appropriate with healthcare providers and interdepartmental teams, to assess medical necessity of care for member
• Collects, documents, and maintains all member clinical information accurately in health management systems to ensure compliance with regulatory guidelines
• Provides training to Utilization Management team to promote high quality care to members & clients
• Resolves or facilitates resolution of the highest risk and/or complex prior authorization issues
• Identify opportunities to create efficiencies in the UM program and activities, collaborate to design and implement improvements
• Participate in Internal UM Committee
• Comply with all JVHL policies and standards

Other Roles and Responsibilities:

• Develop/maintain memberships in professional organizations
• Maintain valid licensure
• Contribute to other areas and perform duties at JVHL as needed
• Ability to work independently and collaboratively in a fast-paced environment
• Update job knowledge by participating in education opportunities
• This position will require access to Patient Health Information (PHI), both electronic and hardcopy, so employee will be required to assist in its protection by following corporate policies and procedures that are designed to maintain the privacy and security of PHI.

Education/Qualifications:Graduate from an Accredited School of Nursing or bachelor’s degree in nursing and 2 – 4 years of related experience.

Experience in case review, utilization management and prior authorization requests

Preferred Skills:

 Familiarity with clinical decision-making criteria and evidence-based guidelines used in the prior authorization process

 Knowledge of Medicare and Medicaid regulations

Knowledge of NCQA Utilization Management processes