Lead Clinical Reviewer

This position receives/responds to incoming calls from referral sources/patients and communicates with providers for CareCentrix and contacts referral sources to advise them of referral status. Reviews utilization information concerning patient care for CareCentrix and matches those needs to available care options within the reauthorization guidelines provided by CareCentrix and patients’ health care. Assists the Supervisor and Manager with coaching, training, call monitoring, reports and mentoring of new associates. Acts as a clinical resource to department specialists, providing expertise and clinical knowledge. Negotiates with providers when needed and stay within the guidelines. Performs Utilization Management and participates in performance improvement activities (specific measurement for contracts). Works under moderate supervision.

In this job you will:

• Manage multiple tasks, be detail oriented, be responsive, and demonstrate independent thought and critical thinking.  
• Work collaboratively with Utilization Management Medical Director, Manger, and Supervisor(s). 
• Assist Supervisor/Manager with coaching, training, call monitoring, reports and mentoring of new associates.  
• Assign and prioritizes clinical cases for team member review based upon clinical urgency and turnaround times.
• Act as a clinical resource for unlicensed Utilization Review Care Coordinators, providing clinical expertise and helping to clarify referral source directives. Receives/responds to requests from unlicensed staff regarding scripted clinical questions and issues. 
• Make on-going authorization decisions for health plans for which CareCentrix manages the reauthorization responsibilities. Issues service reauthorizations for the home care provider based on medical necessity and payer benefit guidelines. 
• Be able to negotiate with providers when needed and stay within the guidelines.  
• Perform an evaluation of referral appropriateness for CareCentrix services.  
• Research/identify all potential payer sources and determines the primary payer.  
• Receive/respond to incoming calls from referral sources/ patients, exchange information to identify the patient’s needs and assist in determining the Company's ability to meet them.  
• Document the outcome of calls and referral acceptance in an automated manner. 
• Contact referral sources to advise them of referral status. Relays referral and utilization information to the clinical team who will deliver the services requested. 
• Access payer fact sheets to determine if the terms of the contract are covered. Works with the Patient Registration team, contracted providers, and patients to identify potential solutions as clinical problems are identified with payer sources.  
• Communicate customer service/provider issues to supervisor for logging and resolution. 
• Participate in and contributes to ongoing utilization management activities and quality audits. Ensures the collection of data for improvement analysis and prepares reports as requested.
• Assist team in implementing and maintaining standardized operational processes to ensure compliance to company policies, legal requirements, and regulatory mandates. 
• Participate in implementing / maintaining operational processes to ensure
• Participate in special projects and performs other duties as assigned.

This job is for you if:

• You have excellent communication, customer service and problem solving skills, as well as the ability to effectively interact with all levels of management.
• You have interacted with a highly diverse clientele.
• You are a team player and possess the ability to adapt to multiple changes.
• You can problem solve difficult situations with internal and external customers.
• You have a high-level of clinical knowledge, communication, customer service and problem-solving skills, as well as, the ability to effectively interact with all levels of management and a highly diverse clientele.
• You hold strong organizational skills and can effectively manage and prioritize tasks.

You should get in touch if:

• You hold an Associate's Degree or Diploma in Nursing/Practical Nursing or the equivalent.
• You are a Registered Nurse/LPN/LVN (based on allowable state practice act) license in any state(s) or jurisdiction in the United States is required.
• You have a minimum of 2 years clinical experience in a clinical setting required.
• You hold expertise in Utilization Management and knowledge of URAC standards.
• You possess a broad knowledge of health care delivery/managed care regulations, contract terms/stipulations, prior utilization management/review experience, and governmental home health agency regulations required.
• You have acquired excellent negotiation, communication, problem solving and decision-making skills also preferred. Required to possess an active license to practice without restrictions. Must have at least 1 year Utilization Management experience.
• You can work a weekly schedule of - Monday and Tuesday 9:00-5:30, Wednesday 11:30-8:00, Thursday and Friday 9:00-5:30 and rotating weekends. 

What we offer:

• Full range of benefits including Health, Dental and Vision with HSA Employer Contributions and Dependent Care FSA Employer Match.
• Generous PTO, 401K Savings Plan, Paid Parental Leave, free on-demand Virtual Fitness Training and more.
• Advancement opportunities, professional skills training, and tuition Reimbursement
• Great culture with a sense of community.

CareCentrix maintains a drug-free workplace.

We are an equal opportunity employer. Employment selection and related decisions are made without regard to age, race, color, national origin, religion, sex, disability, sexual orientation, gender identification, or being a qualified disabled veteran or qualified veteran of the Vietnam era or any other category protected by Federal or State law.

#IDCC

CareCentrix accepts applications on an ongoing basis until a candidate is identified.