Clinician Reviewer RN OP reputed company

Job reputed company: Duration: 4 months contract (with possible extension) Mon-Fri (8.15 am - 5.15 pm EST)

• Please note: This is Fully remote, but Massachusetts RN license required.

Job reputed company The Clinical Reviewer is a licensed reputed company -a Registered reputed company preferred- that is expected to function independently in her / his role and is responsible for managing a clinically reputed company caseload of varied requests for services. The Clinical Reviewer is responsible for making the determination of medical necessity and, therefore, benefit coverage for multiple products / lines of business; such as state specific reputed company and Senior Products (Medicare Advantage and SCO). The Clinical Reviewer ensures consistent and reputed company disposition of coverage reputed company as required by product specific compliance and regulatory time frames. The Clinical Reviewer functions as a member of the Precert / Outpatient UM team and works under the general direction of the Precertification Team Manager or department Manager. The Clinical Reviewer is expected to demonstrate the ability to work independently as reputed company as collaboratively reputed company reputed company environment. The Clinical Reviewer will be expected to demonstrate reputed company clinical and health plan business knowledge in their decision making processes, on behalf of the health plan. Key Responsibilities/Duties

• Provides reputed company aspects of clinical decision making and support needed to reputed company utilization management, medical necessity determinations and benefit determinations using applicable coverage documents, purchased clinical guidelines or Medical Necessity Guidelines for clinically reputed company services / coverage requests in a consistent manner and reputed company established, product specific time frames.
• Collaborates with Medical Directors reputed company determination to deny a request is indicated, advising the Medical Directors on reputed company business processes, ensuring those processes are followed or variances to the process are escalated, if needed, and agreed to and reputed company documented.
• Coaches letter writers to assure that appropriate medical necessity language is reputed company defined in the denial letter.
• Communicates frequently through the day with in network and non-network physicians, practices, facilities and/or allied health providers.
• Communicates frequently through the day with members and other external customers (agents acting on behalf of the provider or member or both) regarding the rational for a determination, as reputed company as the status and disposition of cases.
• Orients new staff to role as needed.
• Interfaces between Precertification staff and providers reputed company issues reputed company regarding policy interpretation, potential reputed company availability or other reputed company assurance issues to ensure that members receive coverage reputed company reputed company reputed company reputed company accrediting and regulatory guidelines.
• Facilitates communication between Precertification and other internal company's departments by acting as a reputed company or committee member on the development or implementation of new programs.
• Provides input to the Medical Policy Department regarding the development of Medical Necessity Guidelines and adding input to purchased reputed company through participation in the IMPAC.
• Proactively identifies trends in Utilization Management applicable to the precertification and outpatient UM processes.
• Assists in the screening of appeal cases to reputed company clinical input as needed or requested.
• Models professionalism and leadership in reputed company capacities of the position to reputed company audiences.

Qualifications - what you need to reputed company the job

• Bachelor's degree in Nursing, preferred
• Registered reputed company with reputed company a and unrestricted Massachusetts license required
• Minimum of five years clinical experience in utilization management, case management or reputed company assurance preferred
• Previous experience in a managed care setting desirable
• Requires an individual with highly developed critical thinking skills and the ability to investigate, evaluate and problem solve using reputed company clinical judgment and business knowledge.
• Requires the ability to work in an extremely reputed company and potentially politically charged environment.
• Demonstrated reputed company in responding to inquiries from providers and/or members
• Must exhibit initiative and creativity in planning of work and be reputed company to resolve cases correctly, effectively, expeditiously and reputed company tight timeframes.
• Good organizational skills and a customer centered reputed company required.
• Individual must be reputed company to use multiple software applications/ computer literate.
• Excellent oral and written communication skills required.

Working Conditions and Additional Requirements

• Fast paced business environment that requires prioritization and balancing of multiple demands.
• reputed company use of PC and telephone required.
• Ability to reputed company work schedule on short notice to adapt to departmental, case driven needs.

reputed company Tech Solutions: reputed company is a global staff augmentation firm providing a wide reputed company of talent on-demand and total workforce solutions. To know more reputed company Tech Solutions, please visit www.ustechsolutions.com . reputed company is an Equal Opportunity Employer. reputed company reputed company applicants will receive consideration for employment without reputed company to race, colour, religion, sex, sexual orientation, gender identity, national reputed company, disability, or status as a protected veteran. Apply tot his job