Clinical Review Specialist

New England Life Care•Canton, MA

About The Position

Primary Job Responsibilities: 1 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 2 Maintain a thorough and comprehensive understanding of regulations, payer contracts, product lines, NELC policies & procedures. 3 Serves as subject matter expert on complex specialty drugs clinical requirements. 4 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 5 Act as a liaison between internal and external customers to resolve systems/process issues and ensure we are obtaining signed physician orders from participating MD’s for government payers. 6 Determine appropriateness and effectiveness of services requested using established medical coverage criteria, guidelines and departmental policies and procedures 7 Contact appropriate physicians and medical facilities to obtain complete detailed written orders timely to complete Medicare DIFs and authorizations 8 Responsible for timely and comprehensively 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. 9 Effectively and accurately communicate coverage decisions to members, providers and medical groups, following timelines established by regulations and accreditation standards. 10 Identify and appropriately inform Manager/Supervisor of sensitive or complex cases 11 Maintains a thorough and comprehensive understanding of state and federal regulations, accreditation standards and payer contracts in order to ensure compliance. 12 Develop and maintain positive, effective working relationships with Medical Directors, physicians, vendors, managed care offices and other customers 13 Maintain confidentiality of member and case information by following Corporate Privacy policies pertaining to protection of member PHI 14 Perform other duties as assigned

Requirements

Registered Nurse in good standing
Minimum of three (3) years clinical practice experience as an RN in medical/surgical, critical care, home care, or equivalent knowledge of current hospital and clinical care processes
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 or discharge planning
Excellent nursing assessment skills
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 personal computer skill including Microsoft work, outlook and internet

Nice To Haves

Bachelors of Science in Nursing 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 MD’s 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 comprehensively 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 in order 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