Clinical Review Specialist

3 weeks ago


MagstattleBas, Grand Est, United States Actalent Full time
Job Overview:

We are seeking a detail-oriented Clinical Review Specialist to join our team. As a key member of our healthcare services team, you will be responsible for ensuring compliance with State and Federal regulations, as well as internal mandates related to claims and preauthorization processing.

This role involves accurate and timely medical review of claims, preauthorizations, and customer service inquiries. You will also be involved in special projects such as training new hires, provider outreach, project work, peer mentoring, new system implementation, and system testing.

Main Responsibilities:

  • Ensure compliance with State and Federal regulations, as well as internal mandates for claims and preauthorization processing.
  • Perform accurate and timely medical reviews of claims and preauthorizations.
  • Handle customer service inquiries related to claims and preauthorizations.
  • Complete special projects, including training new hires, provider outreach, project work, peer mentoring, new system implementation, and system testing.
  • Determine availability of benefits according to company contracts, endorsements, and medical policy.
  • Verify member eligibility prior to medical review.
  • Foster constructive relationships with all departments.
  • Maintain professional licensure and practice within the scope of licensure.
  • Collaborate and consult with healthcare providers, members, and an internal team of clinical support specialists, nurses, physicians, medical directors, and pharmacists to ensure medically appropriate, high-quality, cost-effective care.

About the Role:

This is a 100% remote position. The core shift is Monday to Friday, 7 am to 5 pm CST, but there are options for flexible shifts, including Tuesday to Saturday or Sunday to Thursday.

Salary Information:

The estimated salary for this position is $90,000 - $125,000 per year, depending on experience and qualifications.



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