Clinical Reviewer
Location: Tampa Florida
Description: CareCentrix is presently looking of Clinical Reviewer right now, this position will be placed in Florida. For detail informations about this position opportunity kindly read the description below. The core function is to review utilization information concerning patient care for CareCentrix and to match those needs to available care options, within the CareCentrix guidelines and specific plan payer crite! ria. Handles verification of all referrals funneled through Triage, verifying information, applying business rules and determining the next steps. Acts as a clinical resource to department care coordinators, providing expertise and clinical knowledge. This position, using clinical expertise, receives/responds to incoming calls from referral sources/potential clients and CareCentrix Care Coordinators and performs administrative assessments of each referral's appropriateness for CareCentrix services. Researches/identifies all potential payer sources and determines the primary payer. Participates in utilization and quality assessment/improvement activities. Works under moderate supervision.
PRIMARY RESPONSIBILITIES
Using clinical expertise, reviews utilization information concerning patient care and matches those needs to available care options, within the CareCentrix guidelines and specific plan payer criteria.
Handles verification of all referrals ! funneled through Triage, verifying information, applying busin! ess rules and determining the next steps. Acts as a clinical resource to department care coordinators, providing expertise and clinical knowledge.
Receives/responds to incoming calls from referral sources/potential clients, exchanges information to identify the clients needs and determines CareCentrix' ability to meet them.
Receives and responds to requests from unlicensed staff regarding scripted clinical questions and issues.
Holds all referrals until all information is verified as complete and the next steps are determined.
Records the outcome of all inquiries and referral calls received, and makes follow - up calls when an inquiry or referral cannot be serviced. Tracks/reports on inquiries/referrals and identifies alternative resources when CareCentrix solutions are not available.
Performs an initial evaluation of the referrals appropriateness for CareCentrix services, researches/identifies all potential payer sources and det! ermines the primary payer. Documents demographic/clinical/payer information and determines coverage availability for requested services and passes information on in a timely manner.
Recommends to Team Leader - Intake the acceptance of referrals that do not meet CareCentrix guidelines as appropriate. Coordinates internal activities to ensure a smooth transition from CareCentrix to the provider.
Develops/maintains a working knowledge of all CareCentrix services and accesses CareCentrix contract information, including the terms of the contract as appropriate. Interacts with referral sources to facilitate communications, answer questions and resolve problems.
Required Skills
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 Experience
To perform this job successfully, an ind! ividual must be able to perform each essential duty satisfactorily. The! requirements listed below are representative of the knowledge, skill and/or ability required.
Broad knowledge of health care delivery/managed care regulations, contract terms/stipulations, prior utilization management/review experience, and governmental home health agency regulations required. Excellent negotiation, communication, problem solving and decision making skills also required. Licensed professionals are required to possess a current 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: Tue, 09 Jul 2013 07:52:27 GMT