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Review Specialist

Topeka, KS
Company: KFMC Health Improvement Partners
Job Title: Review Specialist
Job Classification: Non-Exempt, Full-Time
Schedule: Mutually determined
Location: Topeka (Hybrid work option)

About us: KFMC Health Improvement Partners (KFMC) is a not-for-profit organization focused on improving healthcare quality. We inspire meaningful change and sustained high performance within the organizations and communities where we work. We’re a diverse team of multi-disciplinary professionals all focused on the same vision…best health outcomes for everyone. We believe our team members do their best work when they love what they do, and we have created an environment that fosters creativity, excellence and fun! We prioritize and value the things that are important to us, both as people and as professionals, including flexibility and a family-friendly culture. KFMC is currently seeking a Review Specialist. As a member of the Clinical Care Review Team, this position will support our clinical care review activities in Oklahoma and Kansas. The Review Specialist is responsible for interacting with our panel of peer reviewers (PRs), including physicians, mid-levels and other types of direct care providers. The Review Specialist is responsible for scheduling PRs for our various review programs, recruiting providers to serve as reviewers, maintaining PR recruitment files, conducting PR internal quality control (IQC) activities, typing and proofing determination letters, and coordinating the distribution of medical records to reviewers to ensure reviews are completed within provided timelines. The ideal candidate will have experience working directly with physicians and other care providers in a provider office or other clinical setting; at least two years of prior experience in a healthcare setting is required. Business or vocational graduate in a health-related course of study is required; Medical Assistant is preferred.

Primary Accountability:
This position is responsible for scheduling peer reviewers (PRs) for all review programs, recruiting reviewers, serving as the initial contact person for PRs in the KFMC office, maintaining PR recruitment files, and conducting PR internal quality control (IQC) activities. Peer reviewers may be physicians, mid-level practitioners, behavioral health clinicians, etc. Processes credentialing and recredentialing applications for health care providers. Mails, reviews, and verifies credentialing applications. Sets up and maintains provider information in an online credentialing database system. Tracks license and certification expirations for all providers to ensure timely renewals. Supports, develops and maintains relationships with all clinical reviewers (i.e. physicians, midlevel, other practitioners) of KFMC’s PR panel. Serves as contact person regarding peer reviewers for all review activities. This position also acts as the contact person for provider organizations submitting medical records. Coordinates distribution of medical records. Requests, receives, organizes, distributes, and retrieves patient medical records for review activities. This position works in collaboration with internal staff members and/or departments as well as external sources to complete contract duties.

Major Duties:
I. PR Support Services
A. Scheduling
  • Schedule PR reviews for all programs.
  • Prepare, track, and distribute cases to PRs for all review programs.
  • Receive, track, and distribute cases from PRs to appropriate staff for all review programs.
  • Monitor the distribution and timely completion of physician reviewed records.
  • Orient and direct PRs in fulfilling their review responsibilities.
  • Coordinate cases to ensure the oldest cases in each area of review are reviewed by a PR on a timely basis.
  • Maintain familiarity with URAC standards for PR review and individual contract peer review requirements.
  • Communicate to other team members any areas that require additional follow-up or direction beyond the scope of this position’s responsibilities.
  • Offer ideas and recommend changes toward ongoing improvement of peer review activity.
  • Enter timing and/or new PR information into PR IQC database.
  • Update PR maintenance file in PR database.
  • Data enter PR information on each case in the case review database.
  • Coordinate PR reimbursement and be the contact person for all PR inquires and activity.
B. Lead PR recruitment of KFMC PR panel with the assistance of the Credentialing Committee.
  • Assist the Director with the coordination of the Credentialing Committee.
  • Communicate with the PR IQC/Credentialing Committee on problematic PRs.
  • Complete action steps as directed by the PR IQC/Credentialing Committee members.
  • Disseminate PR IQC database reports at PR IQC Committee meetings.
  • Coordinate ongoing PR education and newsletter updates
  • Data enter PR IQC information into database.
  • Maintain PR IQC files.
III. Medical Record Handling
  • Prepare medical records for electronic distribution to PRs.
  • Track due dates for reviews to be completed.
  • Communicate with PRs who have outstanding reviews regarding timelines and due dates.
  • Process completed reviews (i.e. Case Review data base data entry, develop and mail necessary letters, clarify vague PR comments with clinical staff).
IV Other Support Activities
  • Keep manager and Review Team informed of all activities within area of responsibility.
  • Back up duties of Sr. Review Coordinator and Review Assistant.
  • Ensure confidentiality is maintained.
  • Monitor and track review timeliness.
  • Contribute to the achievement of organizational and work team goals by demonstrating awareness of KFMC Values and Mission Statement.
  • Assist in development, revision, and implementation of KFMC programs, policies, and procedures.
  • Other duties as assigned.
  • Business or vocational graduate in a health-related course of study required; Medical Assistant preferred. Significant training and experience in a health-related field may be substituted for educational requirements.
  • Experience interacting with health care providers is preferred.
  • At least two (2) year of prior experience in a health care setting.
  • Experience in the ambulatory/physician office setting or medical records department is preferred.
  • Intermediate to advanced computer skills is required.
  • Must be able to interact with KFMC staff, physicians, hospital personnel, a variety of professionals, and the public in a tactful, diplomatic manner to establish rapport and win confidence.
  • Ability to gather large amounts of data, analyze, evaluate and disseminate in a succinct and effective manner.
  • Strong written and verbal communication skills, including comfort and experience with public speaking.
  • Interpersonal skills to collaborate effectively with internal and external customers.
  • Strong attention to accuracy and detail required.
  • Creative and strategic-thinking abilities.
  • Critical thinking and problem-solving abilities.
  • Ability to identify and initiate process improvements.
  • Strong organizational skills and the ability to coordinate multiple projects.
  • Professional attitude and the ability to maintain confidentiality.
  • Demonstrated ability to work independently and as a team member.
  • Able to travel with occasional overnight stays.
  • Case Review staff with specific credentials required by their position description will provide a copy of their current credential status, and subsequent renewals to the Case Review Manager and Human Resources. Case Review staff are required to report an adverse change in the status of a required credential within three business days of receiving notice from the credentialing authority. Staff may submit a notice of adverse change in a credential by any format and will submit a plan to bring the credential into compliance with the requirement of their Position Description.
Physical Demands:
  • Ability to sit for extended periods of time.
  • Ability to read computer screens and mail.
  • Ability to unpack and move supplies up to 25 lbs.
  • Ability to drive an automobile.
  • Ability to travel as directed by position requirements.
Work Environment:
  • Professional and deadline-oriented environment in an office or remote work setting.
  • Interaction with internal and external customers
Additional Duties: Additional duties and responsibilities may be added to this job description at any time. The job description does not state or imply that these are the only activities to be performed by the employee(s) holding this position. Employees are required to follow any other job-related instructions and to perform any other job-related responsibilities as requested by their supervisor.
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