Medical Reviewer

• Ensure data readiness for important milestones
• Review participant level data across a study in adherence with CRF Completion guidelines and the Data Review Plan
• Conduct point-to-point data checks and interpretive analysis
• Generate queries on discrepant data and follow to resolution
• Create and use data review best practices and associated data review tools
• May identify protocol deviations during routine clinical review and escalation as appropriate
• Follow relevant SOPs and regulations
• Liaise with data management, clinical and site management along with other members of the study team
• Attend Clinical Meetings and Study Meetings, as necessary

Clinical Data Reviewer – Internal Medicine

• Prior authorization review of physical and behavioral health related services
• Utilization of clinical skills to coordinate, document, and communicate all aspects of the utilization/benefit management program
• Application of critical thinking and knowledge of clinically appropriate treatment, evidence-based care, and medical necessity criteria for appropriate utilization of services for members with disabilities and special healthcare needs
• Taking provider calls related to prior authorization questions and making calls to members to inform of the coverage determination
• Gathering clinical information and applying appropriate medical necessity criteria/guideline, policy, procedure, and clinical judgment, in order to render coverage determination/recommendation/discharge planning along the continuum of care
• Utilization of clinical experience and skills in a collaborative process to evaluate and facilitate appropriate healthcare services/benefits for members
• Identification of members who may benefit from care management programs and facilitation of the referral
• Identification of opportunities to promote quality effectiveness of healthcare services and benefit utilization
• Sedentary work involving periods of sitting, talking, and listening
• Performing other duties as assigned.

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Clinical Data Reviewer – Internal Medicine

Prior Authorization Clinical Reviewer