Clinician

• Performs clinical reviews needed to resolve and process appeals by reviewing medical records and clinical data to determine medical necessity for services in accordance with policies, guidelines, and NCQA standards
• Prepares case reviews for Medical Directors by researching the appeal, reviewing applicable criteria, and analyzing the basis for the appeal
• Ensures timely review, processing, and response to appeal in accordance with State, Federal and NCQA standards
• Communicates with members, providers, facilities, and other departments regarding appeals requests
• Generates appropriate appeals resolution communication and reporting for the member and provider in accordance with company policies, State, Federal and NCQA standards
• Works with leadership to increase the consistency, efficiency, and appropriateness of responses of all appeals requests
• Partners with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry best practices
• Performs other duties as assigned
• Complies with all policies and standards

Clinical Review Clinician performing appeals reviews in behavioral health for Centene.

Clinical Review Clinician – Appeals, Behavioral Health

Clinical Review Clinician performing behavioral health appeals reviews for Centene's Medical Management team. Responsible for ensuring compliance with clinical data, policies, and NCQA standards.

• Responsible for complex cases that may require evaluation of multiple variables against guidelines when procedures are not clear
• Serves as a resource to lower-level clinicians and staff
• May collaborate with leadership to assist in process improvement initiatives to improve the efficiency and effectiveness of the utilization reviews within the medical management processes
• Assesses and applies medical policies and clinical guidelines within scope of licensure
• Conducts and may approve pre-certification, concurrent, retrospective, out of network and/or appropriateness of treatment setting reviews by utilizing appropriate medical policies and clinical guidelines in compliance with department guidelines and consistent with the members eligibility, benefits and contract
• May process a medical necessity denial determination made by a Medical Director
• Develops and fosters ongoing relationships with physicians, healthcare service providers and internal and external customers to help improve health outcomes for members
• Refers complex or unclear reviews to higher level nurses and/or Medical Directors
• Educates members about plan benefits and physicians
• Collaborates with leadership in enhancing training and orientation materials
• May complete quality audits and assist management with developing associated corrective action plans
• May assist leadership and other stakeholders on process improvement initiatives
• May help to train lower-level clinician staff

Medical Management Clinician Senior role at Elevance Health

Senior Medical Management Clinician

Medical Management Clinician Senior role focusing on complex cases at Elevance Health. Ensuring appropriate administration of plan benefits and collaborating with healthcare providers.

• Assists responsible RN in identifying members for high risk complications
• Obtains clinical data as directed by the responsible RN
• Assists the responsible RN in identifying members that would benefit from an alternative level of care or other waiver programs
• Provides all information collected to the responsible RN
• Participates in coordinating care for members with chronic illnesses, co-morbidities, and/or disabilities as directed by responsible RN

LTSS Service Coordinator-Clinician for working with individuals with chronic illnesses

LTSS Service Coordinator – Clinician

LTSS Service Coordinator-Clinician assisting responsible RN in care coordination for individuals with chronic illnesses. Working virtually full-time with a focus on member case management.

• Responsible for overall management of member's case within the scope of licensure
• Provides supervision and direction to non-RN clinicians participating in the member's case
• Develops, monitors, evaluates, and revises the member's care plan
• Performs face-to-face clinical assessments for identification, evaluation, coordination and management of member's needs.
• Coordinates care in conjunction with the member and the health care team
• Assists with implementation of member care plans by facilitating authorizations/referrals for utilization of services
• Interfaces with Medical Directors, Physician Advisors and/or Inter-Disciplinary Teams on care management treatment plans
• Directs and supervises the work of any non-RN clinicians in coordinating services for the member

LTSS Service Coordinator-RN Clinician managing member's care in Tennessee

LTSS Service Coordinator – RN Clinician

LTSS Service Coordinator-RN Clinician managing case and coordinating care for members in Tennessee. Ensuring health care optimization and collaboration with treatment teams across various medical needs.

• Assists in identifying members for high risk complications.
• Obtains clinical data as directed.
• Assists in identifying members that would benefit from an alternative level of care or other waiver programs.
• Provides all information collected to the responsible RN.
• Participates in coordinating care for members with chronic illnesses, co-morbidities, and/or disabilities as directed by responsible RN.

LTSS Service Coordinator – Clinician managing members' long term service care coordination in Tennessee

LTSS Service Coordinator – Clinician, LSW, LCSW, LPN

LTSS Service Coordinator – Clinician managing the care coordination of members' needs in Tennessee healthcare industry. Responsible for assessing and monitoring cases for members with chronic illnesses and disabilities.

Clinician jobs in Tennessee

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Clinical Review Clinician – Appeals, Behavioral Health

Senior Medical Management Clinician

LTSS Service Coordinator – Clinician

LTSS Service Coordinator – RN Clinician

LTSS Service Coordinator – Clinician, LSW, LCSW, LPN