Be part of something bigger—make an impact in a growth organization! CareCentrix is committed to making the home the center of patient care.
The core function of the Clinical Reviewer 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.
•Acts as a clinical resource to department care coordinators, providing expertise and clinical knowledge.
•Uses 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.
• 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.
• 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.
• 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.
• Associate's Degree or Diploma in Nursing/Practical Nursing.
• Must be an active Registered Nurse/LPN/LVN (based on allowable state practice act) license in any state(s) or jurisdiction in the United States is required. Licensed professionals are required to possess a current license to practice without restrictions.
• 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.
CareCentrix maintains a drug-free workplace in accordance with Florida's Drug Free Workplace Law.