SMS Clinical Reviewer
Location: Tampa Florida
Description: CareCentrix is at present looking to employ SMS Clinical Reviewer right now, this position will be placed in Florida. More complete informations about this position opportunity kindly read the description below. This position receives/responds to incoming requests from referral sources/patients and communicates with providers for Sleep Management Solutions (SMS) a wholly owned subsidiary of CareCentr! ix, Inc. Contacts referral sources to advise them of referral status. Reviews utilization information concerning patient care for SMS and matches those needs to available care options within the guidelines provided by SMS and patients’ health care. Acts as a clinical resource to department staff, providing expertise and clinical knowledge. Negotiates with providers when needed and stay within the guidelines. Performs Utilization Management and participates in performance improvement activities (specific measurement for contracts). Works under moderate supervision.
Primary Responsibilities
Receives/responds to requests from unlicensed staff regarding scripted clinical questions and issues.
Documents the outcome of calls and referral acceptance in an automated manner.
Relays referral and utilization information to the clinical team who will deliver the services requested.
Access payer fact sheets to determine if the terms of the ! contract are covered. Works with the Patient Registration team! , contracted providers and patients to identify potential solutions as clinical problems are identified with payer sources.
Communicates customer service/provider issues to supervisor for logging and resolution.
Assists team in implementing and maintaining standardized operational processes to ensure compliance to company policies, legal requirements and regulatory mandates.
Participates in implementing / maintaining operational processes to ensure compliance to Company policies, legal requirements and regulatory mandates.
Required Skills
This position requires high level clinical knowledge, communication, customer service and problem solving skills, as well as, the ability to effectively interact with all levels of management and a highly diverse clientele.
Must have:
Strong organizational skills
Ability to effectively manage and prioritize tasks.
Strong commitment to quality and standards. !
Ability to negotiate with providers when needed and stay within the guidelines.
Excellent negotiation, communication, problem solving and decision making skills also required
Expertise in Utilization Management and knowledge of regulatory and accrediting agency standards.
Broad knowledge of health care delivery/managed care regulations, contract terms/stipulations, prior utilization management/review experience, and governmental home health agency regulations required
Required Experience
Associate's Degree or Diploma in Nursing/Practical Nursing or the equivalent and Registered Nurse/LPN/LVN (based on allowable state practice act) licensure in the state(s) of practice required. Required to possess an active license to practice without restrictions.
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If you were eligible to this position, please email us your resume, with salary requirements and a resume to CareCentrix.
If you interested on this position just click on the Apply button, you will be redirected to the official website
This position starts available on: Wed, 10 Apr 2013 07:53:26 GMT