Clinical Reviewer - Medicare

Be part of something bigger—make an impact in a growing organization! CareCentrix is committed to making the home the center of patient care.

Clinical Reviewers are responsible for the Utilization Management and review of clinical information for service requests received and to render a medical necessity approval or recommended denial to the Medical Director. As part of this process, you will evaluate information concerning patient care and match those needs with available care options, consistent with CareCentrix guidelines and specific plan payer criteria.

In this Job, you will

• Interact with the Medical Director as needed to ensure proper medical necessity decisions are being made in a timely manner.
• Use clinical expertise, review clinical information and clinical criteria (e.g., CMS, MCGs, Interqual) to determine if the service/device meet medical necessity for the patient.
• Develops/maintains a working knowledge of all CareCentrix services/guidelines/policies and accesses CareCentrix contract information, including the terms of the contract as appropriate.
• Ensure case review and elevation to complete the determination is rendered within the contractual and regulatory turnaround time standards to meet both contractual and regulatory requirements.
• Perform an initial evaluation of the referral appropriateness for CareCentrix services. Review for information needed to make a medical necessity determination.
• Request additional clinical information when needed to render a decision and determine next steps.

This is the job for you if

• You have experience working remotely and are self-motivated.
• You are willing to work a full time position and can have various work shifts which may be required as needed.
• You manage multiple tasks, are detail oriented, responsive, and demonstrate independent thought and critical thinking.
• You possess strong computer skills, including the ability to navigate multiple internal systems, programs and external sites to conduct reviews.
• You can be a clinical resource to department care coordinators, providing expertise and clinical support.

You should get in touch if (experience & education)

• You hold a broad knowledge of health care delivery/managed care regulations, contract terms/stipulations, prior utilization management/review experience, and governmental home health agency regulations preferred.
• You have a minimum of 1-2 years prior authorization experience for Medicare or Medicare Advantage Home Health required.
• You have an Associate's Degree or Diploma in Nursing/Practical Nursing (required)
• You possess proficient analytical, negotiation, communication, problem solving and decision making skills (required).
• You hold an active, current and unrestricted license (required).
• You hold strong knowledge of Medicare PDGM and 1-2 years process experience strongly desired.
• You have 1-2 years' experience in Interqual (desired).
• You are a Registered Nurse/LPN/LVN with Licensure in the state(s) of practice (based on allowable state practice act)
• You have a minimum of 2 years in a clinical setting (required).

What we offer

• Advancement opportunities, professional skills training, and tuition Reimbursement
• Great culture with a sense of community.
• Full range of benefits including Health, Dental and Vision with HSA Employer Contributions and Dependent Care FSA Employer Match.
• Generous PTO, 401K Savings Plan, Paid Parental Leave, free on-demand Virtual Fitness Training and more.

CareCentrix maintains a drug-free workplace.

#IDCC

We are an equal opportunity employer. Employment selection and related decisions are made without regard to age, race, color, national origin, religion, sex, disability, sexual orientation, gender identification, or being a qualified disabled veteran or qualified veteran of the Vietnam era or any other category protected by Federal or State law.