Apply clinical skills and expertise in conjunction with established medical criteria
Maintain a thorough and comprehensive understanding of regulations, payer contracts, product lines, NELC policies & procedures
Review clinical documentation for long term government payers twice a year
Act as a liaison between internal and external customers
Determine appropriateness and effectiveness of services requested
Responsible for timely and comprehensive medical review with concise documentation
Effectively communicate coverage decisions to members, providers, and medical groups
Identify and appropriately inform Manager/Supervisor of sensitive or complex cases
Develop and maintain positive working relationships with Medical Directors, physicians, vendors
Maintain confidentiality of member and case information

Medical Assistant certification required
MA or LPD preferred
Associate of Arts degree or higher preferred
Healthcare experience in a medical setting required
Prior experience in care coordination, home health or home infusion preferred
Experience in managed care environment
Experience in working with established criteria to determine medical necessity and appropriateness of care
Experience in utilization review, utilization management, quality review
Working knowledge of federal/state fraud and abuse laws required
Knowledge of HIPAA Privacy and Security Regulations preferred

New England Life Care

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