Clinical Review Specialist

Role Overview

• Apply clinical skills and expertise in conjunction with established medical criteria, members’ eligibility and benefit coverage information, in the review of therapy checklists & specialist drug authorization forms, to ensure high-quality, cost-effective care
• Maintain a thorough and comprehensive understanding of regulations, payer contracts, product lines, NELC policies & procedures.
• Serves as subject matter expert on complex specialty drugs clinical requirements.
• Review clinical documentation for long term government payers to ensure they still meet clinical coverage twice a year. Consulting with the Medical Director for all potential denials that do not meet medical necessity or NELC criteria.
• The decision for a medically necessary denial is within the Medical Director role
• Act as a liaison between internal and external customers to resolve systems/process issues and ensure we are obtaining signed physician orders from participating MDs for government payers.
• Determine appropriateness and effectiveness of services requested using established medical coverage criteria, guidelines and departmental policies and procedures
• Contact appropriate physicians and medical facilities to obtain complete detailed written orders timely to complete Medicare DIFs and authorizations
• Responsible for timely and comprehensive medical review with concise documentation of pertinent facts, decisions and rationale and facilitation of resolution to requests of “urgently needed, not yet rendered services” in compliance with state regulation.
• Effectively and accurately communicate coverage decisions to members, providers, and medical groups, following timelines established by regulations and accreditation standards.
• Identify and appropriately inform Manager/Supervisor of sensitive or complex cases
• Maintains a thorough and comprehensive understanding of state and federal regulations, accreditation standards and payer contracts to ensure compliance.
• Develop and maintain positive, effective working relationships with Medical Directors, physicians, vendors, managed care offices and other customers
• Maintain confidentiality of member and case information by following Corporate Privacy policies pertaining to protection of member PHI
• Perform other duties as assigned

Requirements

• Medical Assistant certification required
• MA or LPD preferred
• Associate of Arts degree or higher are 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!