Clinical Review Specialist

1 month ago


Allentown, United States The CKHobbie Group Full time

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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