CenterLight Health System QUALITY CLINICAL REVIEW SPECIALIST in Flushing, New York
Under the direction of the SDR Unit Lead, the Quality Review Specialist is responsible to review, triage, process, and/or investigate, as necessary, all service determination requests received. Will perform a quality review of all data submitted by the IDT teams and PACE Service Coordinators in Care Compass. The role will ensure that service determination requests (SDRs) are handled in a timely and efficient manner and in compliance with the relevant policies & procedures. The role will also perform a variety of duties involving entering, confirming, and updating patient service support documentation. This will include frequent communication with participants and collaboration with various teams within to effectively collect and process participant data. JOB RESPONSIBILITIES:
Reviews daily tasks and assign SDR cases for coordination with IDT and timely resolution.
Provides all administrative-related information and routes accordingly for proper clinical review
Completes SDR assessments and coordination notes into Care Compass EMR database related to SDR process, approved services, delivered services, etc.
Collaborates with Inter-disciplinary Team (IDT), CSDs, and Care Delivery Supervisors to ensure service determination requests (SDRs) are completed timely.
Works closely with site-associated Care Delivery department to ensure data is entered correctly and timely.
Reviews documentation completeness related to the rationale for all service determination requests (SDRs) IDT decisions.
Outreaches participants, caregivers, representatives, IDT members and others to keep them informed about requests’ status or resolution.
Keeps IDT members updated with SDR process status.
Coordinates, documents & follows up with staff in different department's issues and/or requests resolutions.
Completes assigned daily/weekly notification calls for all SDR decisions, including appeal rights information for denials and partial approvals.
Completes validation calls to participants, caregivers or representatives to confirm that all approved services were received timely.
Prepares detailed written responses to all participants/caregivers/representatives regarding the resolution of the service request.
Responsible to complete, scan/upload into EMR all denial letters, including date-stamped mailing envelopes.
Assists with follow-up and escalation of SDR step process as necessary.
Provides general administrative support as needed.
Monitors daily and weekly pending SDR case reports.
Maintains departmental quality and productivity goals.
Adheres to all applicable compliance requirements and the Code of Conduct.
Weekly Hours: 40
Schedule: 8:30 AM - 5:30 PM
EDUCATION: Associate's Degree in business, health care, or related field, or equivalent, with relevant customer service experience and excellent writing skills.
Able to pass typing-test with at least 35 WPM
Excellent written and verbal communication skills (grammar, spelling, and punctuation)
Ability to thrive in a fast-paced environment and meet assigned deadlines
Excellent organizational skills, accuracy, and attention to detail
Demonstrated ability to manage multiple projects and be flexible.
Ability to operate both independently and collaboratively as required
Proficiency in Microsoft Office suite, including Word, Excel, and Outlook
CenterLight Health System is one of the oldest non-profit comprehensive healthcare organizations in the United States. We are a premier provider of home and community-based healthcare and services in the New York metropolitan area, serving all five boroughs of New York City, as well as Westchester, Nassau and Suffolk Counties.
Through CenterLight TeamCare, we offer comprehensive healthcare and other services that enrich the lives of our participants and let them live safely at home and in their communities. TeamCare, a program of CenterLight Healthcare, is the nation’s largest not-for-profit Program of All-Inclusive Care for the Elderly (PACE). Each day, our employees serve a richly diverse population of 3,300 participants, speaking 75 languages and dialects throughout our 14 facilities. Learn more at www.centerlightteamcare.org.
Need help creating an account? Contact CenterLight HR Helpline 718-321-4246.