Clinical Reviewer

4 weeks ago

Canton, United States US Tech Solutions Full time

Duration: 6 months contract (with possible extension)


Employment Type: W-2


Note: Utilization Review or Utilization Management Nursing background is highly preferred.


Job Description:

· Coordinates the review process for services requiring prior authorization by company. This includes matching the coverage request to the Medical Necessity Guidelines/Interqual Criteria or Plan Benefit Documents, documentation of the coverage determination in electronic clinical documentation systems, and notification to the requesting provider of coverage determinations within established time frames.


Responsibilities:

· Collects all documentation necessary for coverage determinations and prepares cases for Medical Director Review, including the procurement of Plan Benefit Documents and Medical Necessity Guidelines, documents Medical Director coverage determinations. Notifies providers and/or members of the coverage determination within established time frames.

· Interprets Plan Benefit Documents for all products to ensure appropriate benefit determination.

· Assists Member and Provider Services in responding to external coverage inquiries.

· Is responsible for drafting written correspondence to members and providers pertaining to coverage determinations based on explicit instructions and specific guidelines.


Experience:

· Candidate should have at least 5 years of experience as a nurse. We find there are many different backgrounds that translate well to this position.

· They could have experience in an insurance setting, acute, sub-acute or long-term care settings, a physician’s office, home care, or hospice.

· This position does require computer experience, and both written and verbal communication to providers.


Skills:

· This should be an RN with a valid Massachusetts nursing license, preferably with UR or UM experience. This is a remote position but there could be a possibility of being required to go in office at times.


Education:

· BSN or Bachelors of Science in Nursing preferred. Equivalent UR or UM experience is fine.


About US Tech Solutions:

US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To know more about US Tech Solutions, please visit www.ustechsolutions.com.


US Tech Solutions is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.


Recruiter Details:

Name: Pushpendu

Email: pushpendu@ustechsolutions.com

Internal Id: 24-04850

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