Clinical Review Specialist

This is a fully remote position, open to applicants in Maine, +2 more states.

📋 Description

• Utilize clinical skills and expertise alongside established medical criteria, members’ eligibility, and benefit coverage details while reviewing therapy checklists and specialist drug authorization forms to guarantee high-quality, cost-effective care.

• Maintain an extensive understanding of regulations, payer contracts, product lines, and NELC policies and procedures.

• Serve as the subject matter expert on the clinical requirements of complex specialty drugs.

• Review clinical documentation for long-term government payers biannually to ensure continued compliance with clinical coverage, consulting with the Medical Director regarding any potential denials that do not meet medical necessity or NELC criteria.

• The decision regarding a medically necessary denial falls under the responsibility of the Medical Director.

• Act as a liaison between internal and external customers to resolve system/process issues and ensure we secure signed physician orders from participating MDs for government payers.

• Assess the appropriateness and effectiveness of requested services using established medical coverage criteria, guidelines, and departmental policies and procedures.

• Contact relevant physicians and medical facilities to obtain comprehensive and timely written orders necessary to complete Medicare DIFs and authorizations.

• Responsible for conducting timely and thorough medical reviews with clear documentation of relevant facts, decisions, and rationale, and facilitating resolutions for requests pertaining to “urgently needed, not yet rendered services” in accordance with state regulations.

• Effectively and accurately communicate coverage decisions to members, providers, and medical groups, adhering to timelines established by regulations and accreditation standards.

• Identify and inform the Manager/Supervisor about sensitive or complex cases appropriately.

• Maintain a thorough understanding of state and federal regulations, accreditation standards, and payer contracts to ensure compliance.

• Develop and sustain positive, effective working relationships with Medical Directors, physicians, vendors, managed care offices, and other stakeholders.

• Safeguard the confidentiality of member and case information by adhering to Corporate Privacy policies regarding the protection of member PHI.

• Perform other duties as assigned.

⛳️ Requirements

• Medical Assistant certification is required.

• MA or LPD is preferred.

• An Associate of Arts degree or higher is preferred.

• Healthcare experience in a medical setting is required.

• Prior experience in care coordination, home health, or home infusion is preferred.

• Experience in a managed care environment.

• Experience working with established criteria to assess medical necessity and appropriateness of care.

• Experience in utilization review, utilization management, and quality review.

• A working knowledge of federal and state fraud and abuse laws is required.

• Knowledge of HIPAA Privacy and Security Regulations is preferred.

🏝️ Benefits

• Health insurance.

• Dental insurance.

• Vision insurance.

• Generous employer-matched 403(b) savings program.

• Company-paid life insurance, short- and long-term disability insurance.

• Paid Time Off.

• And much more!