Clinical Program Coord II

Clinical Program Coord II

We're looking for colleagues who are ready to Think Big, Go Fast, Deliver Awe, and Win Together.
These core values embody our diverse and inclusive culture and help us live out our mission of "getting people the care they need when they need it." Over the last 30 years, our company has established itself as the market leader in managed care for the workers' compensation industry.
We are committed to making a positive impact in the lives of the injured workers we serve, and we have fun doing it.

Salary Range: 16.50 - 21.39 Hourly

This compensation range takes into account the wide range of factors that are considered in making compensation decisions including but not limited to skill sets; experience and training; licensure and certifications; and other business and organizational needs.
The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the position may be filled.
At One Call, it is not typical for an individual to be hired at or near the top of the range for their role and compensation decisions are dependent on the facts and circumstances of each case.
A reasonable estimate of the current range is 16.50 - 21.39 Hourly

Benefits Summary:
In return for your commitment to our company's mission, we offer a vast array of benefits to help support the whole you.

• Opportunities to work from home
• Competitive wages with opportunities to earn annual merit increases
• Paid development hours to use for professional and community development!
  
• Generous paid time off, 8 company holidays, and 2 floating holidays per year
• $1,000 Colleague Referral Program
• Enterprise Recognition Program rewarding colleagues for their extraordinary work
• Exclusive discounts on travel, activities, and merchandise via work discount program
• Colleague Assistance Program that provides free counseling and financial services
• Tuition Reimbursement Program including certifications
• Quantum Health: A healthcare navigation platform to help our colleagues make the best, most cost-effective healthcare decisions
• Medical, dental, and vision insurance
• Pre-Tax FSA and HSA health savings accounts
• 401(k) matching
• Company paid life insurance
• Company paid short term and long-term disability
• Referral program
• Healthcare concierge
• The One Call Foundation which aims to help colleagues during unexpected emergencies, from car accidents to natural disasters.
  

JOB SUMMARY:

The DX Clinical Program Coordinator manages the referral handling components of the Clinical Review process for various service types, to enable successful completion and in a timely manner.
They work closely with the One Call licensed Clinical Reviewers and assist in communication of professionally rendered recommendations, while maintaining and strengthening professional relationships with internal and external customers.
The DX Clinical Program Coordinator must be able to thoroughly audit the referrals, to confirm referral data integrity for appropriate implementation of the Clinical Review process and the respective various outcomes of the team's recommendations.

GENERAL DUTIES & RESPONSIBILITIES:

Data Integrity: 40%

• Audits referral to confirm appropriate candidacy for Clinical Review: identifying and correcting errors, validating Rx/auth/treatment for body part and diagnosis, and validating Progress Summaries on file
• Reviews the entire completed Gold Standard Review™ for accuracy and avoidance of non-supported language or recommendations.
• Monitors discharge dates input on Gold Standard Review™ to determine why referral has not been discharged and if a discharge Gold Standard Review™ is needed.
• Processes the Discharge Queue to input data from Provider Discharge Summaries for relaying One Call outcomes to customers.
• Reviews Functional Capacity Evaluation documentation to confirm all required information is present per respective request type

Communication: 35%

• Gathers all information to email and/or fax to payor.
• Communicates Gold Standard Review™ results to Adjuster and/or Case Manager, including any outstanding provider or reviewer requests for information.
  
• Handles all correspondences with Adjuster and/or Case Manager to obtain original or modified authorization for the injured worker.
• Updates referral authorization and relays to provider or revises authorization already given to provider.Communicates requirements to payors and providers on needed information for independent clinical reviews.

Collaboration: 25%

• Adheres to all insurance company client directives and escalates any needs for additions or modifications.
• Provides re-education and support regarding One Call's Gold Standard Review™ program to payor and providers with various inquiries.
• Works closely with core Operations teams to handle all Case Rate Program referral appeals, Letter of Medical Necessity's, diagnosis change requests.
• Handles the At Risk Program, to include tracking the triggering of candidates and reporting outcomes.
• Serves as primary contact for any PT Clinical related needs for other One Call products and teams.
• Educates providers on the avoidance of alternative service recommendations within FCEs, pursuing addendums when needed.

EDUCATIONAL AND EXPERIENCE REQUIREMENTS:

• Associate's degree is required; Bachelor's degree is preferable; or the equivalent combination of education, training, and work experience.
• Prefer experience in clinical or medical office setting.
  
• Experience in a therapeutic rehabilitation setting is premium.
  
• Must have an introductory level understanding of clinical or medical terminology.

GENERAL KNOWLEDGE, SKILLS & ABILITIES:

• Excellent verbal and written communication skills.
• Excellent interpersonal and customer service skills.
• Excellent organizational skills and attention to detail.
• Excellent time management skills with a proven ability to meet deadlines.
• Strong analytical and problem-solving skills.
• Ability to prioritize tasks and to delegate them when appropriate.
• Ability to function well in a high-paced and at times stressful environment.
• Proficient with Microsoft Office.

PHYSICAL/EMOTIONAL DEMANDS & WORK ENVIRONMENT:

• For roles located in office or home settings; this job is primarily sedentary and may involve repetitive motions; the employee is regularly required to sit, use hands and fingers, speak, and hear.
• The employee is occasionally required to lift objects (up to 10lbs weight; up to 4 ft. height).
• Specific vision abilities required by this job include ability to see things from a close distance and ability to adjust focus
• The emotional demand of the job may cause undue stress from, but not limited to, moderate/heavy workload.
• Reasonable accommodations will be individually assessed and possibly made to enable individuals with disabilities to perform the essential functions of the position.
• Please be advised this job description is subject to change at any time.