• Lead Clinical Reviewer

    Job Locations Remote
    Job ID
    Clinical/Utililization Management
  • Overview

    The Lead Clinical Reviewer 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. Responsible for reviewing 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. 


    • 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.
    • Performs an evaluation of referral appropriateness for CareCentrix services.
    • Researches/identifies all potential payer sources and determines the primary payer.
    • Receives/responds to incoming calls from referral sources/ patients, exchanges information in order to identify the patient's needs and assist in determining the Company's ability to meet them.
    • Documents the outcome of calls and referral acceptance in an automated manner.
    • Contacts 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.
    • Communicates customer service/provider issues to supervisor for logging and resolution.
    • Participates in and contributes to ongoing utilization management activities and quality audits. Ensures the collection of data for improvement analysis and prepares reports as requested.
    • Assists team in implementing and maintaining standardized operational processes to ensure compliance to company policies, legal requirements and regulatory mandates.
    • Participates in implementing / maintaining operational processes to ensure compliance to Company.
      Participates in special projects and performs other duties as assigned.


    • Associate's Degree or Diploma in Nursing/Practical Nursing--Registered Nurse/LPN 
    • 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
    • Excellent negotiation, communication, problem solving and decision making skills 
    • 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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