Clinical Reviewer, Nurse Practitioner / Physician Assistant – Oncology

Role Overview

• Conducts initial clinical review of incoming cases, rendering authorization approval based on established clinical criteria or escalating to a Field Medical Director if authorization cannot be approved during initial review.
• Responsible for acting as a clinical liaison to providers, clients, and patients as directed by the office of the Chief Medical Officer.
• Responsible for clinical conversations with providers and their office staff regarding medical necessity decisions.
• Responsible for maintaining and operating the Guideline Directed Treatment plans including communicating with offices regarding treatment recommendation.
• Responsible for communicating need for additional clinical information to ordering providers.
• Responsibility for prepping cases which cannot be approved and which the provider will not modify or withdraw for P2P discussions with one of the Oncologists.
• Responsible for coordinating with UM staff to ensure timely and accurate communication of clinical decisions.
• Responsible for completion of UM projects and participation in site visit reviews.
• Respect and maintain HIPAA confidentiality guidelines.
• Responsible for maintaining availability to clinical and non-clinical administrative staff during performance of initial and second level screening.
• Acts as an interdepartmental liaison between all offices, departments, and committees.
• Serve as subject matter expert and participate in meetings as assigned with practices and/or payers.
• Will work with the Director of Clinical Operations to ensure client satisfaction.
• Perform all peer clinical review activities while located in a state or territory of the United States.
• Acts with honor and integrity, serving as a role model for the company.
• Performs other duties as assigned.

Requirements

• Master of Science in Nursing or Doctor of Nursing Practice (DNP) degree from a recognized degree program OR a master’s degree from a program accredited by the ARC-PA
• Minimum of three (3) to five (5) years’ experience in the practice of Oncology (required)
• Knowledge of regulatory requirements with at least two years of experience in a regulatory role (preferred)
• Current, unrestricted state PA or RN/NP license in medicine or required specialty
• If a PA, obtaining a passing score on a national certifying exam
• Obtaining and maintaining required licenses, per business need
• Strong clinical, management, communication, and organizational skills.
• Demonstrated leadership skills
• Analytic skills
• Energetic and curious with a passion for quality and value in health care
• Required to pass skills proficiency test

Benefits

• Health insurance benefits
• Comprehensive benefits for qualifying employees