Clinical Review Specialist

New England Life Care•Canton, MA

9d•$24 - $25•Remote

About The Position

New England Life Care (NELC), a nonprofit home infusion provider serving more than 70 hospital systems in Maine, New Hampshire, and Massachusetts, is hiring a remote Clinical Review Specialist. The position conducts utilization management reviews and provides clinical information to confirm patient coverage. Remote employees must live in Maine, Massachusetts, or New Hampshire. The ideal schedule is Monday through Friday, 8:30 a.m. to 5:00 p.m. The role requires strong communication and deductive reasoning skills and the ability to work in a fast-paced environment.

Requirements

Medical Assistant certification is required.
Healthcare experience in a medical setting is required.
Experience in a managed care environment.
Experience applying established criteria to determine medical necessity and appropriateness of care.
Experience in utilization review, utilization management, or quality review.
Working knowledge of federal and state fraud and abuse laws is required.
Dependability in attendance and job performance.
Excellent verbal and written communication and interpersonal skills.
Excellent problem-identification and problem-solving skills.
Ability to organize and prioritize multiple assignments within the workload.
Ability to work independently and take independent action within the scope of job responsibilities.
Computer skills, including Microsoft Word, Outlook, and internet use.
Must live in Maine, Massachusetts, or New Hampshire to be hired for this remote position.

Nice To Haves

MA or LPN qualification.
Associate of Arts degree or higher.
Prior experience in care coordination, home health, or home infusion.
Knowledge of HIPAA Privacy and Security Regulations.

Responsibilities

Apply clinical skills and established medical criteria, eligibility, and benefit information to review therapy checklists and specialist drug authorization forms, supporting high-quality, cost-effective care.
Maintain a thorough understanding of regulations, payer contracts, product lines, and NELC policies and procedures.
Serve as a subject matter expert on clinical requirements for complex specialty drugs.
Review clinical documentation for long-term government payers twice a year to confirm continued coverage; consult the Medical Director about potential denials that do not meet medical necessity or NELC criteria. Medically necessary denial decisions are the Medical Director’s responsibility.
Liaise with internal and external customers to resolve systems and process issues and obtain signed physician orders from participating physicians for government payers.
Determine whether requested services are appropriate and effective using established medical coverage criteria, guidelines, and departmental policies and procedures.
Conduct timely, comprehensive medical reviews; document relevant facts, decisions, and rationale; and facilitate resolution of requests for urgently needed, not-yet-rendered services in compliance with state regulation.
Communicate coverage decisions accurately and effectively to members, providers, and medical groups within regulatory and accreditation timelines.
Identify sensitive or complex cases and inform the Manager or Supervisor appropriately.
Maintain understanding of state and federal regulations, accreditation standards, and payer contracts to ensure compliance.
Develop and maintain effective working relationships with Medical Directors, physicians, vendors, managed care offices, and other customers.
Protect member and case confidentiality by following corporate privacy policies for handling protected health information.
Perform other duties as assigned.