CareCentrix

  • Lead Clinical Reviewer

    Job Locations US-FL-Tampa
    Job ID
    2018-5957
    Category
    Post Acute Care / Clinical
  • Overview

    Come join a dynamic, growing team in an innovative, game-changing, healthcare organization. CareCentrix

    is committed to making the home the center of patient care.

     

    Responsibilities

    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.


    - Manage multiple tasks, be detail oriented, be responsive, and demonstrate independent thought and critical thinking.

    - Works collaboratively with Utilization Management Medical Director, Manger, and Supervisor(s).

    - Assists Supervisor/Manager with coaching, training, call monitoring, reports and mentoring of new associates.

    - Assigns and prioritizes clinical cases for team member review based upon clinical urgency and turnaround times.

    - Acts 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.

    - Makes 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.

    - Performs an evaluation of referral appropriateness for CareCentrix services. - Researches/identifies all potential payer sources and determines the primary payer.

     - Communicates customer service/provider issues to supervisor for logging and resolution.
     
     

    Qualifications

    Associate's Degree or Diploma in Nursing/Practical Nursing or the equivalent and Registered Nurse/LPN/LVN (based on allowable state practice act) license in any state(s) or jurisdiction in the United States is required Expertise in Utilization Management and knowledge of URAC standards. Broad knowledge of health care delivery/managed care regulations, contract terms/stipulations, prior utilization management/review experience, and governmental home health agency regulations required. 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. CareCentrix maintains a drug-free workplace in accordance with Florida's Drug Free Workplace Law.

     

     

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