Job Title: Clinical Coordinator (Health Plans)

Job Type: Full-Time

Job Location: Noida, India

Job Summary

The Clinical Coordinator has a well-developed knowledge and skill set in utilization management (UM), medical necessity, and care coordination. This individual is responsible for performing a variety of prospective, concurrent, and retrospective UM-related activities. These operations are primarily focused on utilization management and communications.

The coordinator works with clinical team members, such as pharmacists, nurses, and pharmacy technicians, to ensure that clinical activities are completed according to accreditation and regulatory requirements. Ensure timely, customer focused in delivering quality care.

Job Responsibilities (but not limited to):

The primary responsibilities involve assisting by coordinating activities of medical utilization management team in configuring, testing, and maintaining systems and processes to deliver quality care.

Clinical Coordination

- Performs prospective, concurrent, and retrospective medical necessity reviews for healthcare products and services utilizing appropriate clinical criteria and/or evidence-based guidelines.
- Ensures regulatory and/or accreditation guidelines are met for timeliness of medical necessity reviews.
- Verifies accuracy of codes and services and applies them accurately with appropriate documentation.
- Communicates member, provider, and facility notifications, citing clinical criteria and Medical Director denial rationale, when indicated.
- Process incoming and outgoing referrals, and prior authorizations, including intake, notification, and census roles.
- Assist the clinical staff with setting up documents/triage cases for Clinical Coverage Review.
- Handle resolution/inquiries from members and/or providers.

Utilization Management Analysis & Testing

- Evaluates, coordinates, manages, and documents all UM-related activities.




- Maintains a current knowledge of medical necessity criteria and UM-related policies and procedures.
- Participates in the monitoring of the effectiveness and outcomes of the UM program.
- Comply with all regulatory and accreditation standards related to utilization management and/or case management.
- Help with Utilization management reviews and testing the systems to make sure upgrades went well, etc.
- Assists with developing communications (e.g., letters, forms) and configuration within the platforms in compliance with state and federal requirements.
- Provides support for internal and external audits.
- Stays abreast of new regulations to ensure regulatory and compliance applicable to clinical operations.
- Assist in resolving incoming appeals, complaints, and grievances.

Qualifications:

Education and/or Training:

- Bachelors degree in any medical education. (Essential)
- Post-Graduation in healthcare related field or MBA (Healthcare or equivalent degree). (Desired)

Professional Experience:

- Minimum two (2) years of prior experience in utilization management, clinical coordination related to health plans or case management is preferred.
- Knowledge of US Healthcare System; specifically, Medicare is highly preferred.
- Experience with Medicare Advantage plans with knowledge of CMS guidance/regulations is preferred.
- Must have a regard for confidential data and adherence to corporate compliance policy.

2. Licenses/Certifications:

- Utilization Management or Case Management certification is preferred. (Desired)

3. Specialized Skills:

- Employ effective use of knowledge and critical thinking skills.
- Apply effective time and project management skills.
- Strong interpersonal skills
- Performance management skills
- Results driven individual

4. Technical Skills:

- Robust PC skills; MS Word, Excel, Access, and Power Point.

5. Additional Considerations:

- Applicants must be able to pass a background investigation as all offers are pending a successful completion of background check per the company policy.

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