Clinical Review Specialist

New England Life Care•Scarborough, ME

10h•Remote

About The Position

New England Life Care (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 collaborative serving more than 70 hospital systems in Maine, New Hampshire, and Massachusetts. NELC was created by local hospitals to ensure their patients have access to a provider that reflects their commitment to excellence in patient care, quality, and service. Like our owner hospitals, NELC provides patient focused care. New England Life Care 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! New England Life Care currently has a Remote Clinical Review Specialist opportunity available. This is a remote position with an ideal Monday – Friday from 8:30am until 5:00pm schedule. The ideal candidate for this position will excel 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. Summary: The Clinical Review Specialist will conduct regular utilization management reviews and provide clinical information as required in order to confirm coverage for each patient.

Requirements

Medical Assistant certification required
Healthcare experience in a medical setting required
Working knowledge of federal / state fraud and abuse laws required
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 within workload
Ability to function independently and take independent action, within scope of job responsibilities
Competency in computer skills including Microsoft work, outlook and internet

Nice To Haves

MA or LPD preferred
Associate of Arts degree or higher are preferred
Prior experience in care coordination, home health or home infusion preferred
Experience in managed care environment
Experience in working with established criteria to determine medical necessity and appropriateness of care
Experience in utilization review, utilization management, quality review
Knowledge of HIPAA Privacy and Security Regulations preferred.

Responsibilities

Apply clinical skills and expertise in conjunction with established medical criteria, members’ eligibility and benefit coverage information, in the review of therapy checklists & specialist drug authorization forms, to ensure high-quality, cost-effective care
Maintain a thorough and comprehensive understanding of regulations, payer contracts, product lines, NELC policies & procedures.
Serves as subject matter expert on complex 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 all potential denials that do not meet medical necessity or NELC criteria. The decision for a medically necessary denial is within the Medical Director role
Act as a liaison between internal and external 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 criteria, guidelines and departmental policies and procedures
Contact appropriate physicians and medical facilities to obtain complete detailed written orders timely to complete Medicare DIFs and authorizations
Responsible for timely and comprehensive medical review with concise documentation of pertinent facts, decisions and rationale and facilitation of resolution to requests of “urgently needed, not yet rendered services” in compliance with state regulation.
Effectively and accurately communicate coverage decisions to members, providers, and medical groups, following timelines established by regulations and accreditation standards.
Identify and appropriately inform Manager/Supervisor of sensitive or complex cases
Maintains a thorough and comprehensive understanding of state and federal regulations, accreditation standards and payer contracts to ensure compliance.
Develop and maintain positive, effective working relationships with Medical Directors, physicians, vendors, managed care offices and other customers
Maintain confidentiality of member and case information by following Corporate Privacy policies pertaining to protection of member PHI
Perform other duties as assigned