Responsibilities
- Conduct assessments of medical services to validate their appropriateness using established criteria and guidelines, ensuring the medical necessity of treatments (e.g., CMS, Milliman Care Guidelines, InterQual, or health plan specific guidelines/criteria).
- Examine and evaluate patient records to verify the quality of patient care and the necessity of provided services.
- Offer clinical expertise and serve as a clinical reference for non-clinical staff members.
- Input and manage essential clinical details within various medical management platforms.
- Keep up-to-date with regulatory prerequisites (such as URAC) and state standards for utilization review.
- Apply clinical reasoning to determine the suitable evidence-based guidelines.
- Foster efficient and high-quality patient care by effectively communicating with management teams, physicians, and the Medical Director.
- May provide oversight to the work of the team members.
- Continuously improves processes that help to facilitate better turnaround time, peer to peer success rates and lessens returned reports by clients for clarification purposes, ultimately resulting in higher client satisfaction.
- Responsible for the final approval on cases for release to the client.
- Will act as a liaison and coordinate quality issue reports along with all new reviewer reports with the VP of Clinical Operations.
Benefits
- Health insurance
- Dental coverage
- Vision coverage
- Voluntary life insurance options for employee, spouse, and children
- Hospital indemnity
- Critical illness
- Accident indemnity
- Pet insurance plans
- Basic life insurance at no cost
- Short-term disability coverage at no cost
- Long-term disability coverage at no cost
- Generous paid time off policy
- 401k plan with company match
- Apple equipment provided
- Media stipend for remote workspace
Work Arrangement
Remote (Worldwide)
Additional Information
- Work from home technical requirements: candidate must supply and support their own internet services.
- Maintaining an uninterrupted internet connection is a requirement for all work from home positions.
- Long periods of sitting and computer work.
- Any lifting, bending, traveling, etc. required to do the job duties listed above.
