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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.
This position receives referrals from the Intake Department that require review for medical necessity, determination for approval or elevation to the Medical Director. The Clinical Reviewer will own the case from point of referral to the recommendation for denial, or approval decision. If a request is to be denied, the Clinical Reviewer will complete the denial process in collaboration with the Medical Director; if a request is to be authorized, it will then be sent onto the staffing department for completion when appropriate. The Clinical Reviewer will also participate in performance improvement activities as required to meet CareCentrix contract obligations. Works under moderate supervision after successful completion of training and probation period.
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 critieria 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.
Receives/responds to requests for service directed by Clincial Leadership.
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.
Interacts with referral sources to facilitate communications, answer questions and resolve problems.
Participates in ongoing utilization management activities and quality assessment/improvement activities, ensures the collection of data for improvement analysis and prepares reports as requested.
Assists Team Leader in implementing/ maintaining standardized operational processes to ensure compliance to CareCentrix policies, legal requirements and regulatory mandates. Follows Utilization Management and URAC/NCQA standards.
Familiarization with Industry standard guidelines (ie:McKesson/Interqua/MCG) preferred
Attends/participates in development programs and obtains continuing education as required by company policy.
Maintains an active license and renews licensure in a timely fashion.
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.
Participates in an annual Inter-rater reliability Testing Process
Participates in special projects and performs other duties as assigned.
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.
Current and unrestricted license required.
Minumum 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.
Experience working with computers and proficiency in MS Office products including MS Excel, MS Word, and MS Outlook