SCOPE OF POSITION:
Responsible for the facilitation, coordination, and administrative support of review determinations. Coordinate aspects of medical records requests, receipt, tracking, and filing. May prepare review notices as assigned or directed. Maintains file control procedures in accordance with AFMC policy and State and Federal guidelines. Collaborate with medical and professional staff to accomplish goals within designated time frames. Responsible for analyzing patient records to determine legitimacy and necessity of medical services in compliance with government reimbursement policies. Review findings may be referred to a physician advisor for final determination. Collaborate with medical and other professional staff to accomplish goals within designated timeframes. Support the organization’s mission, vision, and values by exhibiting the following behaviors: Honesty, Excellence Accountability, Respect and Teamwork.

ESSENTIAL JOB FUNCTIONS:
1. Transcribe case specific Physician Advisor rationales for use as denial rationale in provider and beneficiary notifications.
2. Refer cases that require clarification or additional rational to the appropriate department Supervisor, Manager, Director, or the Associate Medical Director.
3. May be responsible for initial screening of medical records submitted for authorization of service, limited to the following tasks:
a. Performance of review of service request for completeness of information;
b. Collection and transfer of non-clinical data;
c. Obtaining structured clinical data; and
d. Other review related activities that do not require evaluation or interpretation of clinical information.
e. Seek direction from Clinical Review Specialist, Supervisor, Manager or Director for any clinical related questions or issues during the screening process.
4. Proofread all outgoing correspondence, memos, forms, reports, etc. for accuracy and distribute.
5. Scan, organize, file, maintain and track medical records, departmental records, correspondence, forms, etc. Purge files of inactive charts based on availability of space and AFMC retention/destruction procedures.
6. Receive and distribute all correspondence including mail, fax, memos, reports and e-mail. Maintain contact lists to include addresses, phone numbers and e-mail addresses.
7. Answer incoming calls and route to the proper person. Answer questions and take messages when needed.
a. Upon request, verbally informs patients, facility personnel, the attending physician and other ordering providers, and health professionals of specific utilization management requirements and procedures
b. May inform callers of a list of procedure codes that do not require pre-certification
c. Refers all callers with clinical related questions or concerns to an appropriate clinical staff member
8. Review, verify and edit the work produced by other staff members as directed.
9. Review each selected record accurately and according to AFMC, state and federal policies and procedures.
10. Write effective and accurate review summaries and submit within appropriate time frame.
11. Refer all cases that do not meet established medical necessity criteria to the physician advisor.
12. Maintain files for recording and reporting in accordance with established procedures.
13. Perform site surveys as required or directed if relevant to your department. Must be able to travel within the State as needed to accomplish required site visits if relevant to your department.
14. Prepare monthly reports and/or statistics as directed.
15. Communicate effectively with internal and external clients. Upon request, verbally informs patients, facility personnel, the attending physician and other ordering providers, and health professionals of specific utilization management requirements and procedures
16. Seek direction from Clinical Review Manager, Assistant Clinical Director, Clinical Director of Review, Associate Medical Director, or VP Chief Medical Officer for any clinical related questions or issues during the review process.
17. Daily quotas may be added to meet contract deliverables as needed.
18. Serve as a back up to other team members as assigned or requested.
19. Assist in training new team members.
20. Perform data entry and prepare reports of review activity.
21. Adhere to format, content and style guidelines, giving consideration to usability and ensuring accuracy, consistency, and quality.
22. Follow AFMC, state and federal protocols regarding data confidentiality/security and HIPAA compliance.
23. Communicate needs and requests to other team members as appropriate.
24. Additional duties as assigned.

KNOWLEDGE, SKILLS, AND ABILITIES:

• Intermediate skill level with MS Office (Excel, Word, PowerPoint, and Outlook).
• Type 50 wpm.
• Exceptional skills in business English and spelling are required.
• Ability to maintain confidentiality.
• Strong oral and written communication skills.
• Customer service.
• Creativity.
• Ability to meet deadlines.
• Attention to detail.
• Flexibility.
• Knowledge of ICD 9/ICD 10 Coding.
• Knowledge of HIT/EHR.
• Medical terminology.
• Ability to work collaboratively and independently to achieve stated goals.
• Initiative.
• Ability to relate professionally and positively with staff, business partners, customers, constituents, recipients and the public.
• Ability to multitask.
• Ability to prioritize.
• Strong organizational skills.
• Professionalism.
• Problem solving skills.
• Project management skills.
• Time management skills.
• Ability to read, interpret and apply laws, rules and regulations.
• Knowledge of quality improvement processes and techniques.
• Ability to travel, including overnight travel.

Physical and Sensory Requirements (With or Without the Aid of Mechanical Devices):
Mobility, reaching, bending, lifting, grasping, ability to read and write, ability to communicate with personnel, ability to remain calm under stress and ability to lift and transport 30 pounds. Must be capable of performing the essential functions of this job, with or without reasonable accommodations.

EDUCATION:
Required: Associate’s Degree.
Desirable: Bachelor’s Degree. Licensed mental health professional in the state of Arkansas.

EXPERIENCE:
Required: Two (2) years administrative experience. Three (3) years’ experience in health care, social service, behavioral health, or juvenile justice. Must be trained and possess experience in proper investigative techniques and detailed instruction on writing deficiencies.

Desirable: Experience in healthcare administrative setting. Quality Assurance / Utilization Review and/or coding experience.

INTERNET REQUIREMENTS:
Reliable, high-speed wireless internet service (Wi-Fi)