Clinical Review Coordinator

Soleo Health is seeking a Clinical Review Coordinator to support our Pharmacy Operations Remotely (USA). Join us in Simplifying Complex Care!

Soleo Health Perks:

• Competitive Wages
• 401(k) with a Match
• Referral Bonus
• Paid Time Off
• Great Company Culture
• Annual Merit Based Increases
• No Weekends or Holidays
• Affordable Medical, Dental, & Vision Insurance Plans
• Company Paid Disability & Basic Life Insurance
• HSA & FSA (including dependent care) Options
• Education Assistant Program

The Position:

The Clinical Review Coordinator works closely with all departments to research and provide accurate and timely Clinical Review on complex, patient cases to ensure that approval is secured and to mitigate risk of technical and clinical denials. The Clinical Review Coordinator attempts to resolve denials by utilizing nationally recognized criteria for appeal submission. Responsibilities include:

• Completes prior authorization reviews in a timely manner through their clinical expertise evaluating patient clinicals and payer clinical criteria to determine if the service meets medical necessity of the payer
• Reviews and comprehends patient progress notes, lab reports, infusion summaries, imaging reports, and plan of care. Identifies appropriate medical documentation that satisfies payer medical policy criteria.
• Request additional clinical information when needed to render a decision and/or determine next steps
• Assists with creation of clinical support packets to be used for the initial prior authorization and/or subsequent appeals
• In cases of authorization denials, constructs and documents a succinct and fact-based clinical case to support appeal utilizing appropriate medical necessity criteria and other pertinent clinical facts.
• Creates and maintains, a library of clinical support resources to include templates for appeals, journal articles, other reference tools that can be used to support medical necessity. When existing resources are unavailable search for supporting clinical evidence to support appeals.
• Provides program support by staying current on the top payer covered services, medical necessity requirements and formulary details. Also, must be proficient in locating payer resources related to medical policies.
• Assist with post service insurance denials & appeals
• Participates in outcome programs including but not limited to data entry, reporting functions, and patient calls with necessary to complete denial support tasks
• Provides inter-departmental training to increase teams’ knowledge for top disease states and specialty drugs, clinical requirements, and prior authorization & appeal best practices

Schedule:

• Monday-Friday, 8:30a-5p
• Full-Time

• Experience with specialty infusion needs and challenges required
• Bachelor’s degree in healthcare field or 3 years in a qualified position
• Excellent communication skills (written, oral, and presentation), excellent customer service and interpersonal skills
• Flexible communication style, highly motivated team player with excellent listening skills
• Able to handle stress to meet identified program objectives and manages time effectively
• Self-starter that takes responsibility, is comfortable with accountability and results oriented
• Competent in the use of Word, Excel, and Power Point

About Us: Soleo Health is an innovative national provider of complex specialty pharmacy and infusion services, administered in the home or at alternate sites of care. Our goal is to attract and retain the best and brightest as our employees are our greatest asset. Experience the Soleo Health Difference!

Soleo’s Core Values:

• Improve patients’ lives every day
• Be passionate in everything you do
• Encourage unlimited ideas and creative thinking
• Make decisions as if you own the company
• Do the right thing
• Have fun!

Soleo Health is committed to diversity, equity, and inclusion. We recognize that establishing and maintaining a diverse, equitable, and inclusive workplace is the foundation of business success and innovation. We are dedicated to hiring diverse talent and to ensuring that everyone is treated with respect and provided an equal opportunity to thrive. Our commitment to these values is evidenced by our diverse executive team, policies, and workplace culture.

Soleo Health is an Equal Opportunity Employer, celebrating diversity and committed to creating an inclusive environment for all employees. Soleo Health does not discriminate in employment on the basis of race, color, religion, sex, pregnancy, gender identity, national origin, political affiliation, sexual orientation, marital status, disability, genetic information, age, membership in an organization, parental status, military service or other non-merit factor.

Keywords: intake coordinator, prior authorization specialist, patient care coordinator, referral, specialty pharmacy, appeals, denials