JOB SUMMARY:

Working from instructions and pre-established guidelines, under general supervision, assigns medical necessity requests to a qualified reviewer and follows-up to ensure timely determination is delivered based on state/URAC guidelines in accordance with Concentra policies, practices and procedures.

Ensure the delivery of exceptional customer service by putting all customers (internal and external) first and displaying:

• A healing focus
• A selfless heart
• A tireless resolve

MAJOR DUTIES AND RESPONSIBILITIES:

• Communicates directly with customer and physician advisor and tracks cases to ensure case is completed and returned to customer within established time requirements.
• Receives and reviews physician review requests to ensure that all necessary information is available and contacts customer if additional information is required.
• Assigns cases to appropriate/qualified physician advisor based on case requirements for specific physician specialty, experience, and state licensure requirements.
• Sends requests and all supporting documentation to the physician advisor with an expected return date.
• Upon receipt of completed determination, reviews for spelling and grammatical errors, appropriate application of state guidelines, ensures that all questions have been addressed, and releases the final determination to requesting customer.
• Ensures a case is completed and returned to customer based on promised return date.
• Works any assigned physician review queue and/or communications queue.
• Seeks assistance of more experienced Physician Review Coordinator (PRC) or Supervisor to troubleshoot problem cases.
• Responds appropriately to customer or provider complaints. Refers complaint calls to Supervisor, QA Manager, or Director.
• Performs other duties as assigned.

Concentra's Data Protection Commitment
* Concentra is committed to protect patient data and to ensure privacy of personal and medical information.
* Every Concentra colleague has the responsibility to adhere to data protection principles.
* If a colleague's role includes handling or processing sensitive data, role-specific policies and requirements apply to ensure the protection of patient information.

JOB-RELATED SKILLS/COMPETENCIES:

• Customer focused
• Team oriented
• Good telephone etiquette and customer service orientation
• Ability to handle confidential information
• Knowledge of Microsoft Word and Excel and ability to learn new software applications.
• Team oriented
• Strong written, oral and interpersonal communication skills
• Ability to manage time effectively, set priorities, accommodate multiple demands for time and resources

WORKING CONDITIONS/PHYSICAL DEMANDS:

• Office environment