Genetic Counselor, Clinical Reviewer
The Cigna Group
Clinical Reviewer
CareCentrix
full-time
Posted on:
Location Type: Remote
Location: Remote • 🇺🇸 United States
Visit company websiteSalary
💰 $29 - $38 per hour
Job Level
JuniorMid-Level
About the role
- Perform an initial evaluation of the referral appropriateness for CareCentrix services.
- Review for information needed to make a medical necessity determination.
- Request additional clinical information when needed to render a decision and determine next steps.
- Use clinical expertise, review clinical information and clinical criteria (e.g., CMS, MCGs, Interqual) to determine if the service/device meet medical necessity for the patient.
- Ensure case review and elevation to complete the determination is rendered within the contractual and regulatory turnaround time standards.
- Interact with the Medical Director as needed to ensure proper medical necessity decisions are being made in a timely manner.
- Develop/maintain a working knowledge of all CareCentrix services/guidelines/policies.
Requirements
- Associate's Degree or Diploma in Nursing/Practical Nursing (required)
- Registered Nurse/LPN/LVN with Licensure in the state(s) of practice (based on allowable state practice act)
- Active, current and unrestricted license (required)
- Minimum of 1-2 years prior authorization experience for Medicare or Medicare Advantage Home Health required
- Minimum of 2 years in a clinical setting (required)
- 1-2 years' experience in Interqual (desired)
- Strong knowledge of Medicare PDGM and 1-2 years process experience strongly desired
- Broad knowledge of health care delivery/managed care regulations, contract terms/stipulations, prior utilization management/review experience, and governmental home health agency regulations preferred
- Proficient analytical, negotiation, communication, problem solving and decision making skills (required).
Benefits
- Medical
- Dental
- Vision
- 401(k) with company match
- HSA employer contributions
- Dependent Care FSA employer contribution
- Paid Time Off
- Personal/Sick Time
- Paid Parental Leave
- corporate bonus incentive
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
clinical evaluationmedical necessity determinationprior authorizationInterqualMedicare PDGMutilization managementclinical criteriahealth care delivery regulationsmanaged care regulationscontract terms
Soft skills
analytical skillsnegotiation skillscommunication skillsproblem solving skillsdecision making skills
Certifications
Associate's Degree in NursingRegistered Nurse LicensureLPN LicensureLVN Licensure
