• Conduct all mandatory case review and quality assurance activities • Assure the efficiency of the case review process • Communicate with and support physician reviewers • Edit documentation for internal and external dissemination • Develop and maintain working relationships with community agencies

• Conduct an initial assessment of documentation from both the initiating and responding parties. • Review submitted documentation to identify missing documents and determine what is required to resolve the dispute. • Follow procedures to obtain the appropriate documentation. • Determine the appropriate type of clinical reviewer necessary to complete the case, such as a medical coder or a physician. • Prepare documents for the arbitrator reviewer assigned and provide instructions as needed. • Collaborate with the legal team to facilitate resolution of disputes. • Draft professional determination correspondence. • Perform quality assurance checks on determinations according to Federal or State guidance. • Audit and analyze patient records to ensure appropriate determination. • Stay current with regulation changes and perform research on a case-by-case basis. • Deliver high-quality, professional determinations free of grammar and spelling errors. • Amend reports with additional clinical information when necessary. • Participate in an interdisciplinary health care team to achieve positive outcomes.

• Conduct independent, remote case reviews evaluating medical necessity, appropriateness, or quality of care. • Provide evidence-based assessments and written determinations following established clinical guidelines and review criteria. • Support case types including: Utilization review, Appeals and hearings, Quality of care and standard of care concerns. • Uphold the highest standard of clinical integrity, neutrality, and objectivity.

• The Nurse Educator/Review Coordinator’s primary role is to facilitate provider education related to the claim reviews performed under Task Order 3 for the BFCC-QIO contract. • The education provided will be dependent on the outcome of the reviews and may involve the application of Medicare policy, ICD-10-CM/PCS coding rules, DRG assignment, medical necessity, or other related claim review topics. • Collaborate with staff, management, and the Medical Director to identify billing issues that could improve with provider education. • Provide recommendations related to problem identification and proposed resolutions. • Stay current on the latest evidence for new practices and quality indicators through learning activities, in-services, and information sharing. • Uphold policies, procedures, and standards. • Assist management with assessing staff competencies and needs for training. • Assist management with the inter-rater reliability or other QA processes. • Facilitate education sessions with providers on CMS-required medical record documentation for claim reviews. • Facilitate the construction of final claim review provider letters. • Promote activities to improve provider compliance. • Serve as a liaison between the provider and the QIO. • Perform desktop medical review. • Interpret and apply review criteria as applicable to specific positions. • Communicate with and support physician reviewers by summarizing case facts, preparing case questions, and assisting with resolving issues requiring physician input. • Provide for the dissemination of current information necessary for the successful implementation of contract expectations. • Provide feedback to Managers to assist with evaluation of staff. • Maintain records/data related to job activities and duties. • Protect the confidentiality of patient information through compliance with the Health Insurance Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health Act (HITECH).