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- Job ID
- Clinical / Utililization Management
As a Clinical Reviewer, you will be responsible for the review of clinical information for service requests received and render a medical necessity approval or recommended denial to the Medical Director. You will evaluate information concerning patient care and match those needs with available care options, consistent with CareCentrix guidelines and specific plan payer criteria. You will review referrals for medical necessity and determine approval or elevation to the Medical Director. You will own the case from point of referral to the recommendation for denial, or approval decision. If a request is to be denied, you will complete the denial process in collaboration with the Medical Director; if a request is to be authorized, it will then be sent onto the staffing department for completion when appropriate.
- Performs an initial evaluation of the referrals appropriateness for CareCentrix services. Reviews for information needed to make a medical necessity determination. Requests additional clinical information when needed to render a decision and determines next steps.
- Using clinical expertise, reviews clinical information and clinical critieria to determine if the service/device meets medical necessity for the member.
- Ensure case review and elevation to complete the determination is rendered within the contractual and regulatory turnaround time standards to meet both contractual and regulatory requirements .
Interact with the Medical Director as needed to ensure proper medical necessity decisions are being rendered.
- Receives/responds to requests for service directed by Clincial Leadership.
- Acts as a clinical resource to department care coordinators, providing expertise and clinical knowledge.
- Develops/maintains a working knowledge of all CareCentrix services/guidelines/policies and accesses CareCentrix contract information, including the terms of the contract as appropriate.
- Interacts with referral sources to facilitate communications, answer questions and resolve problems.
- Participates in ongoing utilization management activities and quality assessment/improvement activities, ensures the collection of data for improvement analysis and prepares reports as requested.
- Assists Team Leader in implementing/ maintaining standardized operational processes to ensure compliance to CareCentrix policies, legal requirements and regulatory mandates. Follows Utilization Management and URAC/NCQA standards.
- Maintains an active license and renews licensure in a timely fashion.
- Associate's Degree or Diploma in Nursing/Practical Nursing and Registered Nurse/LPN/LVN/RT (based on allowable state practice act) licensure in the state(s) of practice required.
- Licensed professionals are required to possess a current license to practice without restrictions.
- Minumum of 2 years of experience in a clinical setting
- Broad knowledge of health care delivery/managed care regulations, contract terms/stipulations, prior utilization management/review experience, and governmental home health agency regulations preferred.
- Knowledge of Utilization Management and URAC/NCQA standards.
- Familiarization with Industry standard guidelines (ie:McKesson/Interqua/MCG) preferred
- Experience working with computers and proficiency in MS Office products including MS Excel, MS Word, and MS Outlook.
CareCentrix maintains a drug-free workplace in accordance with Florida’s Drug Free Workplace Law.
We are an equal opportunity employer. Employment selection and related decisions are made without regard to age, race, color, national origin, religion, sex, disability, sexual orientation, gender identification, or being a qualified disabled veteran or qualified veteran of the Vietnam era or any other category protected by Federal or State law.