Lead Clinical Reviewer
- Job Locations: Remote
- Job ID: 2019-7173
- Category: Clinical / Post Acute Care
This position receives/responds to incoming calls from referral sources/patients and communicates with providers for CareCentrix and contacts referral sources to advise them of referral status. Reviews utilization information concerning patient care for CareCentrix and matches those needs to available care options within the reauthorization guidelines provided by CareCentrix and patients’ health care. Assists the Supervisor and Manager with coaching, training, call monitoring, reports and mentoring of new associates. Acts as a clinical resource to department specialists, providing expertise and clinical knowledge. Negotiates with providers when needed and stay within the guidelines. Performs Utilization Management and participates in performance improvement activities (specific measurement for contracts). Works under moderate supervision.
- Manage multiple tasks, be detail oriented, be responsive, and demonstrate independent thought and critical thinking.
- Works collaboratively with Utilization Management Medical Director, Manger, and Supervisor(s).
- Assists Supervisor/Manager with coaching, training, call monitoring, reports and mentoring of new associates.
- Assigns and prioritizes clinical cases for team member review based upon clinical urgency and turnaround times. – Acts as a clinical resource for unlicensed Utilization Review Care Coordinators, providing clinical expertise and helping to clarify referral source directives. Receives/responds to requests from unlicensed staff regarding scripted clinical questions and issues.
- Makes on-going authorization decisions for health plans for which CareCentrix manages the reauthorization responsibilities. Issues service reauthorizations for the home care provider based on medical necessity and payer benefit guidelines.
- Ability to negotiate with providers when needed and stay within the guidelines.
- Performs an evaluation of referral appropriateness for CareCentrix services.
- Researches/identifies all potential payer sources and determines the primary payer.
- Receives/responds to incoming calls from referral sources/ patients, exchanges information in order to identify the patient’s needs and assist in determining the Company’s ability to meet them.
- Documents the outcome of calls and referral acceptance in an automated manner.
- Contacts referral sources to advise them of referral status. Relays referral and utilization information to the clinical team who will deliver the services requested.
- Access payer fact sheets to determine if the terms of the contract are covered. Works with the Patient Registration team, contracted providers and patients to identify potential solutions as clinical problems are identified with payer sources.
- Communicates customer service/provider issues to supervisor for logging and resolution.
- Participates in and contributes to ongoing utilization management activities and quality audits. Ensures the collection of data for improvement analysis and prepares reports as requested. – Assists team in implementing and maintaining standardized operational processes to ensure compliance to company policies, legal requirements and regulatory mandates.
- Participates in implementing / maintaining operational processes to ensure compliance to Company.
- Participates in special projects and performs other duties as assigned.
This position requires excellent communication, customer service and problem solving skills, as well as the ability to effectively interact with all levels of management and a highly diverse clientele. To be successful, the incumbent must be a team player and possess the ability to adapt to multiple changes. Must be able to problem solve difficult situations with internal and external customers. This position requires high level clinical knowledge, communication, customer service and problem solving skills, as well as, the ability to effectively interact with all levels of management and a highly diverse clientele. Must have strong organizational skills and be able to effectively manage and prioritize tasks. Must have a strong commitment to quality and standards. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Ability to negotiate with providers when needed and stay within the guidelines. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
- Associate’s Degree or Diploma in Nursing/Practical Nursing or the equivalent and Registered Nurse/LPN/LVN (based on allowable state practice act) license in any state(s) or jurisdiction in the United States is required
- Expertise in Utilization Management and knowledge of URAC standards. Broad knowledge of health care delivery/managed care regulations, contract terms/stipulations, prior utilization management/review experience, and governmental home health agency regulations required.
- Excellent negotiation, communication, problem-solving and decision making skills also preferred.
- Required to possess an active license to practice without restrictions.
- Must have at least 1-year Utilization Management experience.
- Minimum of 2 years of experience in a clinical setting preferred.