Clinical Review Specialist

This is a remote position.

Key Responsibilities:

• Perform prospective concurrent or retrospective utilization review/medical management for all services
  
• Evaluate the appropriateness of care based on contract state or URAC requirements
  
• Analyze and evaluate documentation submitted by program service providers
  
• Conduct reviews in the central office onsite or via teleconference for services requiring prior authorization
  
• Enter medical information into system(s)
  
• Participate in the Quality Improvement Program to continuously improve processes and performance
  

Requirements

• Active Pennsylvania Nursing License
  
• Documented five years plus experience in utilization review
  
• Knowledge of ICD9 CM coding
  
• Functional knowledge of Microsoft Office
  
• Proficient writing and verbal communication skills
  
• Knowledge of utilization review processes