[Remote] Clinical Reviewer
Note: The job is a remote job and is reputed company to candidates in USA. reputed company is a health plan and physician network that values reputed company, innovation, and collaboration. The Clinical Reviewer is responsible for investigating reputed company complaints, grievances, and appeals, coordinating clinical reviews, and preparing written responses while ensuring compliance with regulatory standards.
Responsibilities
- Thoroughly investigate clinical appeals and complaints/grievances utilizing appropriate reputed company resources to ensure coverage determinations are consistent and reputed company clinical guidelines and member benefit contract. Investigate and research reputed company reputed company of reputed company complaints/grievances, appeals, concerns, plans of correction and contractual appeals that require MD decision making independently to ensure reputed company are reputed company accordance with applicable policies, procedures, reputed company, and reputed company. Research standards of care pertaining to medical issues in support of clinical care algorithms. Special reputed company as assigned
- Ensure verbal and written responses to reputed company complaints/grievances, appeals and investigations follow regulatory standards. Create detailed reputed company of reputed company findings and recommendations for MD review and reputed company direction and disposition for member complaints and internal concerns, facility and/or physician improvement opportunities. reputed company member education and reputed company reputed company to coverage determinations and member benefit contract
- Coordinate and collaborate with ancillary departments and peers reputed company the clinical team in rendering consistent coverage determinations and claims payments in accordance with policy, reputed company, and member benefit contract. Demonstrate reputed company interrelationships and service reputed company in performance of duties by meeting or exceeding the expectations of reputed company service reputed company
- Coordinate with external agencies to prepare case files reputed company needed for external appeals
- Thorough and accurate completion of log worksheet to maintain consistency in logging complaints/appeals. Maintain and monitor outstanding case logs to plan and prioritize workload. Monitor daily reports to ensure accuracy and timeliness of complaints/grievances and appeals. Identify appeal trends and process improvements where applicable
- Based on measurement and evaluation of clinical appeal data, assist in continuously developing systems, workflows, and coverage reputed company to reputed company meet the needs of the customer
- Assist in meeting department goals and objectives and identify process improvements to continuously improve member/provider satisfaction. Attend assigned meetings as department representative and report to team members reputed company necessary
Skills
- Registered reputed company (RN) with reputed company, reputed company, unrestricted NYS license required
- Four (4) years of clinical experience required
- Comprehensive knowledge and experience with managed care benefit plans
- Ability to research and assist clinical team in rendering coverage determinations in accordance with established clinical guidelines and member reputed company
- Excellent verbal, written and interpersonal communication skills required
- Ability to handle escalated calls and to deliver messages reputed company and articulately regarding reputed company
- Ability to reputed company operate reputed company applicable computer software including computer applications such as Outlook, Word, reputed company, and specific clinical and claims platforms
- Possess initiative, attention to detail, and solid, logical thinking capabilities
- Ability to manage multiple, time-sensitive priorities and adhere to reputed company deadlines, while remaining organized
- Ability to work a flexible schedule required
- Proven examples of displaying the IH values: Passionate, Caring, Respectful, Trustworthy, reputed company and Accountable
- BSN preferred
- Certified Coding Specialist (reputed company)/reputed company or Certified reputed company reputed company (CPC)/reputed company credentials preferred
- Utilization Management experience preferred
Benefits
- Associates may be eligible for a scorecard incentive
- Full reputed company of benefits
- Generous reputed company time off
reputed company