Clinical Review Specialist
1 month ago
This is a remote position.
The Clinical Review Specialistwill be responsible for performing prospective, concurrent, or retrospective utilization review/medical management for all services provided by our organization. This role entails evaluating the appropriateness of care based on contract, state, or URAC requirements. They will also analyze and evaluate documentation submitted by program service providers and conduct reviews either in the central office, on-site, or via teleconference for services requiring prior authorization. Additionally, the incumbent will enter medical information into system(s), participate in the Quality Improvement Program to continuously enhance processes and performance, and must maintain an active Pennsylvania Nursing License.
Key Responsibilities:
Perform prospective, concurrent, or retrospective utilization review/medical management for all services
Evaluate the appropriateness of care based on contract, state, or URAC requirements
Analyze and evaluate documentation submitted by program service providers
Conduct reviews in the central office, on-site, or via teleconference for services requiring prior authorization
Enter medical information into system(s)
Participate in the Quality Improvement Program to continuously improve processes and performance
Requirements
Active Pennsylvania Nursing License
Documented five years' plus experience in utilization review
Knowledge of ICD-9 CM coding
Functional knowledge of Microsoft Office
Proficient writing and verbal communication skills
Knowledge of utilization review processes
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