Clinical Review Spec....
Clinical Review Specialist
Posted on :
03-05-2024
Employer Active
1 Vacancy
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Job Description
Req ID : 2786307
This is a remote position.
The Clinical Review Specialist will be responsible for performing prospective concurrent or retrospective utilization review/medical management for all services provided by our organization. This role entails evaluating the appropriateness of care based on contract state or URAC requirements. They will also analyze and evaluate documentation submitted by program service providers and conduct reviews either in the central office onsite or via teleconference for services requiring prior authorization. Additionally the incumbent will enter medical information into system(s) participate in the Quality Improvement Program to continuously enhance processes and performance and must maintain an active Pennsylvania Nursing License.
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
Active Pennsylvania Nursing License Documented five years' plus experience in utilization review Knowledge of ICD-9 CM coding Functional knowledge of Microsoft Office Proficient writing and verbal communication skills Knowledge of utilization review processes
Employment Type
Full Time
Key Skills
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