Clinical Reviewer Job at CareCentrix, Remote

TDl0Z05Qai9KNzA4MC9iMWhXR3lNMGcwV0E9PQ==
  • CareCentrix
  • Remote

Job Description

Clinical Reviewer Location Remote : Overview:

Be part of something bigger—make an impact in a growing organization! CareCentrix is committed to making the home the center of patient care. Clinical Reviewers are responsible for the Utilization Management and review of clinical information for service requests received and to render a medical necessity approval or recommended denial to the Medical Director. As part of this process, you will evaluate information concerning patient care and match those needs with available care options, consistent with CareCentrix guidelines and specific plan payer criteria. Responsibilities: In this Job, you will:

  • Perform an initial evaluation of the referral appropriateness for CareCentrix services. Review for information needed to make a medical necessity determination.
  • Request additional clinical information when needed to render a decision and determine next steps.
  • Use clinical expertise, review clinical information and clinical criteria (e.g., CMS, MCGs, Interqual) to determine if the service/device meet medical necessity for the patient.
  • 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 made in a timely manner.
  • Develop/maintain a working knowledge of all CareCentrix services/guidelines/policies and accesses CareCentrix contract information, including the terms of the contract as appropriate.
  • Peform other duties as assigned by leadership in an effort to support business needs and best serve patients.
This is the job for you if:
  • You can be a clinical resource to department care coordinators, providing expertise and clinical support.
  • You manage multiple tasks, are detail oriented, responsive, and demonstrate independent thought and critical thinking.
  • You possess strong computer skills, including the ability to navigate multiple internal systems, programs and external sites to conduct reviews.
  • You have experience working remotely and are self-motivated.
  • You are willing to work a full time position and can have various work shifts which may be required as needed.
Qualifications: You should get in touch if: (experience & education)
  • You have an Associate's Degree or Diploma in Nursing/Practical Nursing (required)
  • You are a Registered Nurse/LPN/LVN with Licensure in the state(s) of practice (based on allowable state practice act)
  • You hold an active, current and unrestricted license (required).
  • You have a minimum of 1-2 years prior authorization experience for Medicare or Medicare Advantage Home Health required.
  • You have a minimum of 2 years in a clinical setting (required).
  • You have 1-2 years' experience in Interqual (desired).
  • You hold strong knowledge of Medicare PDGM and 1-2 years process experience strongly desired.
  • You hold a broad knowledge of health care delivery/managed care regulations, contract terms/stipulations, prior utilization management/review experience, and governmental home health agency regulations preferred.
  • You possess proficient analytical, negotiation, communication, problem solving and decision making skills (required).
What we offer:
  • Full range of benefits including Health, Dental and Vision with HSA Employer Contributions and Dependent Care FSA Employer Match
  • Generous PTO, 401K Savings Plan, Paid Parental Leave, free on-demand Virtual Fitness Training and more
  • Advancement Opportunities, professional skills training, and tuition /exam reimbursement
  • PayActiv - access earned income in between pay checks
  • Walgreens Discount - receive up to 25% off eligible items
  • Great culture with a sense of community
CareCentrix maintains a drug-free workplace #IDCC

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.

Job Tags

Full time, Contract work, Remote job, Shift work,

Similar Jobs

Care Options for Kids

Pediatric Autism Support Specialist - Join a Dedicated Team (Hiring Immediately) Job at Care Options for Kids

 ...Policy of Care Options for Kids is to provide a fair and equal employment opportunity for all associates and job applicants regardless of race, color, religion, national origin, gender, sexual orientation, age, marital status or disability.*Restrictions Apply#APPABA... 

Geisinger

Laboratory Medicine Supervisor - Evenings and Nights Job at Geisinger

 ...transcription support to Pathologists for research projects, Tissue Arrays and the annual...  ...you and your loved ones can maintain good health, achieve financial stability, and excel both...  ...& pet care. Access free legal guidance, mental health visits, work-life support, digital... 

Beebe Healthcare

APPLICATION PROJECT MANAGER Job at Beebe Healthcare

 ...Insurance Overview: Under the general supervision of the Project Management Office (PMO) Director and working closely with the Chief Information...  ...management experience in a similar healthcare setting. Epic experience is a plus. Competencies Skills: Essential: *... 

HiredChina

Safety Engineer Job at HiredChina

1. With Certifications: CECE, CMSE, and CEFS.2. Bachelor's degree in Engineering, Safety Management, or related field.3. Proven experience in safety engineering within warehouse automation or manufactory automation sector.4. Strong analytical and problem-solving skills... 

Raymour & Flanigan

Visual Merchandiser Job at Raymour & Flanigan

Raymour & Flanigan is looking for an entrepreneurial, talented visual merchandiser that would like to contribute and grow with our company. Our most successful merchandisers have a passion for home furnishings and room design. As part of the showroom team you must be able...