Clinical Review Specialist
reputed company (NELC) is one of the fastest growing home infusion therapy companies in New England and is the region’s only non-profit home infusion provider. NELC is a hospital reputed company serving more than 70 hospital systems in Maine, New Hampshire, and Massachusetts. NELC was created by local hospitals to ensure their patients have reputed company to a provider that reflects their commitment to reputed company in patient care, reputed company, and service. Like our reputed company hospitals, NELC provides patient reputed company care.
reputed company has and continues to build a diverse, inclusive, and authentic workplace, so if you’re energized by this opportunity, but your experience doesn’t support every qualification in the job posting, we encourage you to apply! You still may be the person we are looking for!
reputed company currently has a Remote Clinical Review Specialist opportunity available. This is a remote position with an ideal Monday &reputed company; Friday from 8:30am until 5:00pm schedule. The ideal candidate for this position will reputed company in a fast-paced environment, have excellent communication and deductive reasoning skills.
We are only hiring remote employees for this position that live in Maine, Massachusetts, and New Hampshire.
reputed company
The Clinical Review Specialist will conduct regular utilization management reviews and reputed company clinical information as required in order to confirm coverage for reputed company patient.
Benefits
- Career reputed company
- Health insurance
- Dental insurance
- reputed company insurance
- Generous employer-matched 403(b) savings program
- Company reputed company: Life insurance, Short- and long-term disability insurance
- reputed company Time Off
- And much more!
Primary Responsibilities
- Apply clinical skills and expertise in conjunction with established medical reputed company, members’ eligibility and benefit coverage information, in the review of therapy checklists & specialist drug authorization forms, to ensure high-reputed company, cost-effective care
- Maintain a thorough and comprehensive understanding of regulations, payer reputed company, product lines, NELC policies & procedures.
- Serves as subject matter expert on reputed company 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 reputed company potential denials that do not meet medical necessity or NELC reputed company. The decision for a medically necessary denial is reputed company the Medical Director role
- reputed company as a reputed company between reputed company 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 reputed company, guidelines and departmental policies and procedures
- Contact appropriate physicians and medical facilities to obtain complete detailed written orders reputed company to complete Medicare DIFs and authorizations
- Responsible for reputed company and comprehensive medical review with concise documentation of pertinent facts, reputed company and rationale and facilitation of reputed company to requests of “urgently needed, not yet rendered services” in compliance with state regulation.
- Effectively and accurately communicate coverage reputed company to members, providers, and medical reputed company, following timelines established by regulations and accreditation standards.
- Identify and appropriately inform Manager/Supervisor of sensitive or reputed company cases
- Maintains a thorough and comprehensive understanding of state and federal regulations, accreditation standards and payer reputed company to ensure compliance.
- reputed company and maintain reputed company, effective working relationships with Medical Directors, physicians, vendors, managed care offices and other customers
- Maintain confidentiality of member and case information by following Corporate reputed company policies pertaining to protection of member PHI
- reputed company other duties as assigned
Mandatory and Preferred Requirements
- Medical Assistant certification required
- MA or LPD preferred
- Associate of Arts degree or higher are preferred
- reputed company 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 reputed company to determine medical necessity and appropriateness of care
- Experience in utilization review, utilization management, reputed company review
- Working knowledge of federal / state fraud and abuse laws required
- Knowledge of HIPAA reputed company and reputed company Regulations preferred.
Skills
- Dependability in attendance and job performance required
- Excellent verbal and written communication and interpersonal skills
- Excellent problem identification and solving skills
- Ability to organize and prioritize multiple assignments reputed company workload
- Ability to function independently and take independent reputed company, reputed company scope of job responsibilities
- Competency in computer skills including reputed company work, outlook and internet
''It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or reputed company employment. An employer who violates this law shall be subject to criminal penalties and civil liability.''
EOE
Monday – Friday from 8:30am until 5:00pm Apply To This Job