Clinical review specialist - united states, baltimore
do you have hedis experience and an active nursing license in the va/dc/md area? our client, carefirst is now hiring for clinical review specialists!
responsibilities:
* prospectively reviews requests for high cost, complex inpatient admissions, experimental or cosmetic services, outpatient services, complex expensive durable medical equipment, home care, home infusion and home hospice services medical necessity and benefit coverage determination by analyzing clinical information, contracts, mandates, medical policy, evidence based published research, national accreditation and regulatory requirements and utilizing clinical judgment. determines appropriateness of out-of-network services for hmo members. evaluates employer account transition of care requests for medical necessity. ensures that services for individual accounts are not related to excluded or pre-existing conditions per benefit contract. determines appropriateness of the place of service when requested venue is not supported by milliman care guidelines and other established medical criteria
* 50% conducts preservice reviews for assigned cases. determines medical necessity and appropriateness by referencing regulatory mandates, contracts, benefit information, milliman care guidelines, apollo guidelines, federal employee program and policy guidelines, carefirst medical policy, bluecross blueshield association medical policy, and other accepted medical/pharmaceutical references (i.e. fda, national comprehensive cancer network, clinicaltrials.gov, national institute of health, etc.) conducts research and analysis of pertinent diseases, treatments and emerging technologies, including high cost/high dollar services to support decisions and recommendations made to the medical directors. collaborates with medical directors, sales and marketing, contracting, provider and member services to determine appropriate benefit application. applies sound clinical knowledge and judgment throughout the review process. coordinates non-par provider/facility case rate negotiations between provider contracting, providers and facilities. provides clinical oversight, inventory and quality management of two outsourced vendor agreements. communicates daily with providers, members and carefirst customer service representatives regarding medical necessity and benefits determinations. ensures that all hipaa confidential communication is conducted appropriately for each request.
* 25% daily uses a variety of carefirst legacy and software systems to evaluate member product, contract and benefit eligibility. documents findings in medical management web-based authorization system that supports clinical decisions, demonstrates compliance with departmental, corporate and regulatory standards, claims payment, communication and data collection ensuring that providers have accurate authorization information. will coordinate review and authorizations for clinical services from the provider based access portal “referral/pre-authorization /steerage hub” in compliance with medical affairs 2012 goals. documents in lotus notes database timely and accurately for departmental quality review process and required reporting.
requirements:
-3-5 years of hedis experience in abstracting and/or provider outreach
-active rn license (3-5 years) or lpn license (5-10 years)
-experience with excel and various database/spreadsheet knowledge
-willingness to commute onsite for 1 week training the week of january 30th (remote role otherwise)
-rhit/rhia certification is a plus!
-proof of covid vaccination is required.
what's in it for you:
apply now for immediate consideration!
equal opportunity employer/veterans/disabled
the company will consider qualified applicants with arrest and conviction records
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