Clinical Evaluation and Review
- Receive assigned cases for varied member services (i.e. inpatient, outpatient, DME)
- Review and evaluate cases for medical necessity against medical policy, benefits and/or care guidelines and regulations.
- Complete work in accordance with timeliness, production, clinical quality/accuracy and compliance standards
- Provide notifications to member and/or provider, according to regulatory requirements.
- Assess appropriateness for secondary case review by the Medical Director (MD) for denials and coordinate as needed.
- May coordinate peer-to-peer review upon provider request when members' health conditions do not meet guidelines
Collaboration and Documentation
- Communicate and collaborate effectively with internal and external clinical/non-clinical staff (including MDs) to coordinate work
- Appropriately and fully document outcome of reviews and demonstrate the ability to interpret and analyze clinical information
- Utilize detailed clinical knowledge to summarize clinical review against the criteria/guidelines to provide necessary information for MDs.
Hiring Requirements
- RN with 3 years of clinical experience or LPN with 5 years of clinical experience.
- For Behavioral Health specific roles, other applicable licensure may be considered with a minimum of 3 years of clinical experience.
- Must have and maintain a valid and applicable clinical license (NC or compact multi-state licensure) to perform described job duties.