Clinical Reviewer (SCA-Remote)

Job Summary and Responsibilities

The Clinical Reviewer utilizes clinical expertise during beneficiary interaction in conjunction with contract requirements, critical thinking and utilize decision-making skills to assist with communicating medical appropriateness, while maintaining production goals and QA standards. Ensures day-to-day processes are conducted in accordance with NCQA and other regulatory standards.

Shift Information

This position requires availability to work between 8:00 a.m. and 8:00 p.m. ET, Monday through Friday, and 11:00 a.m. to 6:00 p.m. ET on weekends and holidays.

Job Responsibilities

• Affirms accuracy and timeliness of all applicable review type cases within contract requirements
• Affords assessments, evaluations, and addresses daily workload and call queues; adjusts work schedules daily to meet the workload demands of the department
• In collaboration with Supervisor, responsible for the quality monitoring activities including identifying areas of improvement and plan implementation of improvement areas
• Maintains current knowledge base related to review processes and clinical practices related to the review processes, functions as the initial resource to nurse reviewers regarding all review process questions and/or concerns
• Fosters positive and professional relationships and act as liaison with internal and external customers to ensure effective working relationships and team building to facilitate the review process
• Attends training and scheduled meetings and for maintenance and use of current/updated information for review
• Cross trains and perform duties of other contracts to provide a flexible workforce to meet client/customer needs
• Reads, understands, and adheres to all corporate policies including policies related to HIPAA and its Privacy and Security Rules

Qualifications

• Active, unrestricted LPN or RN license in the applicable state and/or a Compact State license
• Knowledge of the organization of medical records, medical terminology, and disease process required
• Strong clinical assessment and critical thinking skills required
• Medical record abstracting skills required
• 2+ years of clinical experience in a hospital or post-acute environment required

Preferred Qualifications

• Minimum of one year UR and/or Prior Authorization or related experience
• Requires excellent written and verbal communication skills
• Must be proficient in Microsoft Office and internet/web navigation
• Bachelor’s Degree from an accredited college or university in a related field
• Some knowledge of Case Management, UR and/or Prior Authorization or related experience is preferred
• Experience in call center environment a plus
• Experience in a behavioral health setting a plus
• Bilingual (English/Spanish) a plus