CareCentrix

  • Clinical Reviewer

    Job Locations US-CT-Hartford
    Job ID
    2018-5702
    Category
    Clinical/Utililization Management
  • Overview

    Help us keep patients on the path to the ultimate site of care: home. CareCentrix is committed to making home the center of patient care.

    Responsibilities

    The core function is to review utilization information concerning patient care for CareCentrix, and to match those needs to available care options, within the CareCentrix guidelines and specific plan payer criteria. Handles verification of all referrals funneled through Triage, verifying information, applying business rules and determining the next steps. Acts as a clinical resource to department care coordinators, providing expertise and clinical knowledge. This position, using clinical expertise, receives/responds to incoming calls from referral sources/potential clients and CareCentrix Care Coordinators and performs administrative assessments of each referral's appropriateness for CareCentrix services. Researches/identifies all potential payer sources and determines the primary payer. Participates in utilization and quality assessment/improvement activities. Works under moderate supervision.

     

    • Using clinical expertise, reviews utilization information concerning patient care and matches those needs to available care options, within the CareCentrix guidelines and specific plan payer criteria.
    • Verifies completed case verifications funneled through Triage, verifying information, applying business rules and determining the next steps. Acts as a clinical resource to department care coordinators, providing expertise and clinical knowledge.
    • Holds all referrals until all information is verified as complete and the next steps are determined.
    • Records the outcome of all inquiries and referral calls received, and makes follow - up calls when an inquiry or referral cannot be serviced. Tracks/reports on inquiries/referrals and identifies alternative resources when CareCentrix solutions are not available.
    • Performs an initial evaluation of the referrals appropriateness for CareCentrix services, researches/identifies all potential payer sources and determines the primary payer. Documents demographic/clinical/payer information and determines coverage availability for requested services and passes information on in a timely manner..
    • Participates in ongoing utilization management activities and quality assessment/improvement activities, ensures the collection of data for improvement analysis and prepares reports as requested.

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