CareCentrix

  • Clinical Reviewer

    Job Locations US-MI-Detroit
    Job ID
    2018-5741
    Category
    Clinical/Utililization Management
  • Overview

    Come make a difference with a growing organization that is helping to shape the future of healthcare! CareCentrix is committed to making the home the center of patient care. As a Clinical Reviewer you will be responsible for reviewing 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. You will handle verification of all referrals funneled through Triage, verifying information, applying business rules and determining the next steps. Acting 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.

    Responsibilities

    • 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.
    • Receives/responds to incoming calls from referral sources/potential clients, exchanges information to identify the clients' needs and determines CareCentrix' ability to meet them.
    • Receives and responds to requests from unlicensed staff regarding scripted clinical questions and issues.
    • 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.
    • Assists Team Leader in implementing/ maintaining standardized operational processes to ensure compliance to CareCentrix policies, legal requirements and regulatory mandates. Follows Utilization Management and URAC standards.

    Qualifications

    • Current and unrestricted license for the market (state) of practice as a Registered Nurse is required.
    • Minimum of 2 years of experience.
    • Broad knowledge of health care delivery/managed care regulations, contract terms/stipulations, prior utilization management/review experience, and governmental home health agency regulations preferred.
    • Excellent negotiation, communication, problem solving and decision making skills also preferred.
    • Excellent knowledge of Utilization Management and URAC standards. 

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