Senior Clinical Review Specialist
About The Position
New England Life Care (NELC), a nonprofit home infusion therapy provider and hospital collaborative serving more than 70 hospital systems in Maine, New Hampshire, and Massachusetts, is hiring a remote Senior Clinical Review Specialist. The position is remote and limited to applicants who 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 conducts utilization management reviews and provides clinical information needed to confirm patient coverage. It applies clinical expertise and established medical criteria, eligibility, and benefit information to therapy checklists and specialist drug authorization forms, with the aim of supporting high-quality, cost-effective care. The specialist reviews clinical documentation, evaluates requested services, communicates coverage decisions, and helps resolve issues with internal and external customers. Potential medically necessary denials are referred to the Medical Director, who makes those decisions.
Requirements
- Medical Assistant certification.
- Healthcare experience in a medical setting.
- Experience in a managed care environment.
- Experience working with 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.
- Dependable 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 function independently and take independent action within the scope of job responsibilities.
- Computer skills, including Microsoft Word, Outlook, and internet use.
- Applicants must live in Maine, Massachusetts, or New Hampshire.
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, member eligibility, and benefit coverage information when reviewing therapy checklists and specialist drug authorization forms.
- Maintain a thorough understanding of regulations, payer contracts, product lines, and NELC policies and procedures.
- Serve as a subject matter expert on complex specialty-drug clinical requirements.
- Review clinical documentation for long-term government payers twice a year to confirm continued clinical coverage eligibility.
- Consult the Medical Director regarding potential denials that do not meet medical necessity or NELC criteria; medically necessary denial decisions are the Medical Director’s responsibility.
- Liaise between internal and external customers to resolve systems and process issues and obtain signed physician orders from participating physicians for government payers.
- Determine the appropriateness and effectiveness of requested services using established medical coverage criteria, guidelines, and departmental policies and procedures.
- Conduct timely, comprehensive medical reviews and document pertinent facts, decisions, and rationale concisely.
- Facilitate resolution of requests for urgently needed services that have not yet been rendered, in compliance with state regulations.
- 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 positive working relationships with Medical Directors, physicians, vendors, managed care offices, and other customers.
- Protect the confidentiality of member and case information by following corporate policies concerning protected health information.
- Perform other duties as assigned.
Benefits
- Career ladder.
- Health insurance.
- Dental insurance.
- Vision insurance.
- Employer-matched 403(b) savings program.
- Company-paid life insurance.
- Company-paid short- and long-term disability insurance.
- Paid time off.
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What This Job Offers
Job Type
Full-time
Career Level
Senior
Education Level
No Education Listed
