Clinical Reviewer, Precertification RN - Canton, United States - US Tech Solutions, Inc.

Description

• The Clinical Reviewer is a licensed professional –a Registered Nurse preferred– that is expected to function independently in her / his role and is responsible for managing a clinically complex caseload of varied requests for services. The Clinical Reviewer is responsible for making the determination of medical necessity and, therefore, benefit coverage for multiple products / lines of business; such as state specific Medicaid and Senior Products (Medicare Advantage and SCO).
• The Clinical Reviewer ensures consistent and timely disposition of coverage decisions as required by product specific compliance and regulatory time frames. The Clinical Reviewer functions as a member of the Precert / Outpatient UM team and works under the general direction of the Precertification Team Manager or department Manager. The Clinical Reviewer is expected to demonstrate the ability to work independently as well as collaboratively within a team environment. The Clinical Reviewer will be expected to demonstrate sound clinical and health plan business knowledge in their decision making processes, on behalf of the health plan.

• Provides all aspects of clinical decision making and support needed to perform utilization management, medical necessity determinations and benefit determinations using applicable coverage documents, purchased clinical guidelines or Medical Necessity Guidelines for clinically complex services / coverage requests in a consistent manner and within established, product specific time frames.
• Collaborates with Medical Directors when determination to deny a request is indicated, advising the Medical Directors on standard business processes, ensuring those processes are followed or variances to the process are escalated, if needed, and agreed to and well documented.
• Coaches letter writers to assure that appropriate medical necessity language is clearly defined in the denial letter.
• Communicates frequently through the day with in network and non-network physicians, practices, facilities and/or allied health providers.
• Communicates frequently through the day with members and other external customers (agents acting on behalf of the provider or member or both) regarding the rational for a determination, as well as the status and disposition of cases.
• Orients new staff to role as needed.
• Interfaces between Precertification staff and providers when issues arise regarding policy interpretation, potential access availability or other quality assurance issues to ensure that members receive coverage decisions timely within all accrediting and regulatory guidelines.
• Facilitates communication between Precertification and other internal departments by acting as a liaison or committee member on the development or implementation of new programs.
• Provides input to the Medical Policy Department regarding the development of Medical Necessity Guidelines and adding input to purchased criteria through participation in the IMPAC.
• Proactively identifies trends in Utilization Management applicable to the precertification and outpatient UM processes.
• Assists in the screening of appeal cases to provide clinical input as needed or requested.
• Models professionalism and leadership in all capacities of the position to all audiences.

• Bachelor's degree in Nursing, preferred
• Registered Nurse with current a and unrestricted Massachusetts license required
• Minimum of five years clinical experience in utilization management, case management or quality assurance preferred
• Previous experience in a managed care setting desirable
• Requires an individual with highly developed critical thinking skills and the ability to investigate, evaluate and problem solve using sound clinical judgment and business knowledge.
• Requires the ability to work in an extremely complex and potentially politically charged environment.
• Demonstrated skill in responding to inquiries from providers and/or members
• Must exhibit initiative and creativity in planning of work and be able to resolve cases correctly, effectively, expeditiously and within tight timeframes.
• Good organizational skills and a customer centered focus required.
• Individual must be able to use multiple software applications/ computer literate.
• Excellent oral and written communication skills required.