Clinical Review Specialist (31389)

Responsibilities

• Works collaboratively with multiple stakeholders in Infusion Operations to ensure required clinical information is received and reviewed in the infusion intake workflow based on payer and regulatory requirements and lead and manage the appeal process as required.
• Provides clinical oversight and review to ensure the completeness and accuracy of prior approvals based on payer requirements is achieved on all assigned patients and locations.
• Attends to detail regarding required documentation and follows up with outstanding information on a timely basis.
• Collaborates with practice staff, physicians, patients, payers, and infusion department in obtaining needed information to complete job tasks and responsibilities.
• Consistently identifies and tracks information on referrals/ appeals as needed.
• Documents all necessary information in appropriate electronic tools, communicates with appropriate stakeholders timely, and coordinates peer-to-peer communication as per recommended timelines.
• Completes Letters of Medical Necessity or other required clinical documents to assist with the intake and appeal process.
• Completes all reviews within department established policies and best practice standards.
• Prioritizes incoming work appropriately and timely and communicates to all required stakeholders as appropriate at each step of the workflow.
• Serve as a clinical resource to non-clinical staff.
• Afford quality audits and maintain accurate reports.
• Actively participates in the department’s performance improvement initiatives.
• Performs other duties as assigned.

Qualifications

• Education: Nursing Degree or diploma from an accredited institution required. LVN or RN in good standing required.
• Experience: Minimum of five (5) years of relevant nursing experience. Minimum one (1) year of case management and/or utilization review in acute care or insurance-related role.
• Other Qualifications: Infusion experience preferred.