Clinical Review Specialist
New England Life Care
full-time
Posted on:
Location Type: Remote
Location: Maine • Massachusetts • United States
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Salary
💰 $24 - $25 per hour
About the role
- Apply clinical skills and expertise in conjunction with established medical criteria
- Maintain a thorough and comprehensive understanding of regulations, payer contracts, product lines, NELC policies & procedures
- Review clinical documentation for long term government payers twice a year
- Act as a liaison between internal and external customers
- Determine appropriateness and effectiveness of services requested
- Responsible for timely and comprehensive medical review with concise documentation
- Effectively communicate coverage decisions to members, providers, and medical groups
- Identify and appropriately inform Manager/Supervisor of sensitive or complex cases
- Develop and maintain positive working relationships with Medical Directors, physicians, vendors
- Maintain confidentiality of member and case information
Requirements
- Medical Assistant certification required
- MA or LPD preferred
- Associate of Arts degree or higher preferred
- Healthcare experience in a medical setting required
- Prior experience in care coordination, home health or home infusion preferred
- Experience in managed care environment
- Experience in working with established criteria to determine medical necessity and appropriateness of care
- Experience in utilization review, utilization management, quality review
- Working knowledge of federal/state fraud and abuse laws required
- Knowledge of HIPAA Privacy and Security Regulations preferred
Benefits
- Health insurance
- Dental insurance
- Vision insurance
- Generous employer-matched 403(b) savings program
- Company paid: Life insurance, Short- and long-term disability insurance
- Paid Time Off
- And much more!
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
clinical skillsmedical reviewutilization reviewutilization managementquality reviewmedical necessity determinationcare coordinationhome healthhome infusionregulations knowledge
Soft Skills
effective communicationrelationship buildingliaison skillsconfidentiality maintenancesensitivity handling
Certifications
Medical Assistant certificationMALPD