Senior Clinical Review Specialist

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

📋 Description

• Perform regular reviews of utilization management and provide clinical information to verify patient coverage.

• Utilize clinical skills, medical criteria, member eligibility, and benefit coverage details while assessing therapy checklists and specialist drug authorization forms.

• Keep abreast of regulations, payer contracts, product lines, and NELC policies and procedures.

• Act as a subject matter expert on intricate specialty drug clinical requirements.

• Evaluate clinical documentation for long-term government payers biannually to ensure ongoing clinical coverage.

• Consult with the Medical Director regarding potential denials that do not fulfill medical necessity or NELC criteria.

• Serve as a liaison between internal and external clients to address systems/process issues and secure signed physician orders.

• Assess the appropriateness and effectiveness of requested services in accordance with established criteria, guidelines, and departmental policies.

• Conduct timely and thorough medical reviews with clear documentation and address urgently required, yet-to-be-rendered service requests.

• Communicate coverage decisions to members, providers, and medical groups within the timelines set by regulations and accreditation standards.

• Identify and notify the Manager/Supervisor of sensitive or complex cases.

• Ensure compliance with state and federal regulations, accreditation standards, and payer contracts.

• Foster working relationships with Medical Directors, physicians, vendors, managed care offices, and other clients.

• Safeguard member PHI by adhering to Corporate Privacy policies.

• Perform additional duties as assigned.

⛳️ Requirements

• Medical Assistant certification is mandatory.

• An Associate of Arts degree or higher is preferred.

• Experience in a healthcare setting is required.

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

• Background in a managed care environment is advantageous.

• Familiarity with established criteria for assessing medical necessity and appropriateness of care is essential.

• Experience in utilization review, utilization management, or quality review is necessary.

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

• Knowledge of HIPAA Privacy and Security Regulations is preferred.

• Outstanding verbal and written communication skills, along with strong interpersonal skills, are essential.

• Excellent skills in problem identification and resolution are required.

• Ability to organize and prioritize multiple tasks within a given workload is necessary.

• Capability to work independently and take initiative within job responsibilities is important.

• Proficiency in computer skills, including Microsoft Word, Outlook, and internet applications, is necessary.

• Reliability in attendance and job performance is required.

🏝️ Benefits

• Career Ladder.

• Health insurance.

• Dental insurance.

• Vision insurance.

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

• Company-paid life insurance.

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

• Paid Time Off.