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Job Summary:

The Clinical Operations Coordinator organizes and assists daily clinical operations within the organization. These operations are primarily focused on appeals and grievances, utilization management, and communications. The Coordinator works closely with stakeholders to manage daily clinical operations, scope, and quality to meet established service level agreements. The Coordinator works with team members, such as pharmacists, nurses, and pharmacy technicians, to ensure that clinical activities are completed according to accreditation and regulatory requirements.


Job Responsibilities (but not limited to): 

  • Receives inbound calls, faxes, emails, and mail to initiate an appeal, grievance, or prior authorization request.
  • Makes outbound calls to obtain additional information pertaining to an appeal, grievance, or prior authorization request.
  • Collects, organizes, and tracks information received from a variety of resources to facilitate and expedite the processing of requests. 
  • Generates applicable letters for members and providers in accordance with accreditation and regulatory standards. 
  • Assists with business operations in the development of communications (e.g., letters, forms) and configuration within the platforms in compliance with state and federal requirements.
  • Assists with compiling statistical data, reporting, and analyses to demonstrate clinical, financial, and operational effectiveness and quality.
  • Provides support for internal and external audits and surveys.
  • Maintains privacy and confidentiality in all interactions.
  • Follows all state and federal regulations applicable to clinical operations and utilization management.
  • Stays abreast of new regulations to ensure regulatory compliance applicable to clinical operations.
  • Meets established productivity and quality standards.
  • This position has the ability to engage in on-call weekend work.


Education and/or Training:

  • Bachelor’s degree in public policy or a healthcare related field is preferred; equivalent work experience in related field is acceptable.


Professional Experience:

  • At least 2 years relevant experience within a health plan, managed care organization, or third-party administrator is preferred.
  • Experience with appeals and grievances and/or prior authorization processes is 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.


Specialized Skills:

  • Highly developed oral/written communication skills, self-motivation, and ability to work independently with minimal supervision are necessary.
  • Strong organizational skills and attention to detail.
  • Must be flexible and able to constantly review and reset priorities, often daily, and to handle multiple tasks/projects simultaneously.
  • Team player with a collaborative working style.
  • Strong interest in healthcare and technology industries.


Technical Skills:

  • Strong PC skills; MS Word, Excel
  • Access and Power Point skills preferred