- Utilization Management
- NCQA Standards
- Home Care
Be part of something bigger—make an impact in a growing organization! CareCentrix is committed to making the home the center of patient care.
The Clinical Reviewer is responsible for the review of clinical information for service requests received and render a medical necessity approval or recommended denial to the Medical Director. As part of this process, the clinical reviewer will evaluate information concerning patient care and match those needs with available care options, consistent with CareCentrix guidelines and specific plan payer criteria.
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 criteria 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.
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.
Manages multiple tasks, is detail oriented, be responsive, and demonstrate independent thought and critical thinking.
Reviews and adheres to all Company policies and procedures and the Employee Handbook.
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 during time of employment.
Current and unrestricted license required.
Minimum of 2 years of experience in a clinical setting preferred.
Broad knowledge of health care delivery/managed care regulations, contract terms/stipulations, prior utilization management/review experience, and governmental home health agency regulations preferred.
Excellent negotiation, communication, problem solving and decision making skills also preferred.
Excellent communication (verbal/written), organizational and interpersonal skills.
Excellent knowledge of Utilization Management and URAC/NCQA standards.
Licensed professionals are required to possess a current license to practice without restrictions.
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.