Clinical Review Specialist

Role Overview

• 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

Requirements

• 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

Benefits

• Health insurance
• Dental insurance
• Vision insurance
• Generous employer-matched 403(b) savings program
• Company paid: Life insurance, Short
• and long-term disability insurance
• Paid Time Off
• And much more!