Responsibilities
- Evaluates medical services requiring prior approval using clinical judgment and evidence-based standards.
- Spends most of the workday seated, gathering and assessing clinical data via phone interactions with healthcare providers.
- Uses defined clinical criteria to approve services or escalate cases to a Medical Director when necessary.
- Applies professional clinical expertise in a coordinated approach to assess, plan, and monitor healthcare services for members.
- Reviews medical information and applies relevant guidelines, policies, and professional judgment to determine coverage recommendations.
- Engages with providers and stakeholders to support patient care planning and treatment decisions.
- Recognizes opportunities to connect members with additional integrated health programs or services.
- Identifies ways to improve the quality and efficiency of healthcare delivery and benefit use.
- Provides clinical insight and guidance to internal and external partners managing utilization and benefit operations.
Work Arrangement
remote
Responsibilities
- Evaluates medical services requiring prior approval using clinical judgment and evidence-based standards.
- Spends most of the workday seated, gathering and assessing clinical data via phone interactions with healthcare providers.
- Uses defined clinical criteria to approve services or escalate cases to a Medical Director when necessary.
- Applies professional clinical expertise in a coordinated approach to assess, plan, and monitor healthcare services for members.
- Reviews medical information and applies relevant guidelines, policies, and professional judgment to determine coverage recommendations.
- Engages with providers and stakeholders to support patient care planning and treatment decisions.
- Recognizes opportunities to connect members with additional integrated health programs or services.
- Identifies ways to improve the quality and efficiency of healthcare delivery and benefit use.
- Provides clinical insight and guidance to internal and external partners managing utilization and benefit operations.
Other
- Operations run 24/7, with potential for weekend, holiday, and evening shifts.
- This is a fully remote, full-time position.
- Standard hours apply, though occasional weekend or holiday on-call duty may be required.
- Work takes place in a typical office-style setting with expectations for consistent productivity and accuracy.
- Requires close review of both handwritten and digital documents, as well as prolonged screen viewing.
- Role involves sedentary tasks including sitting, speaking, and listening.
- Involves extended periods of sitting, phone communication, and computer typing.
- Must be able to manage multiple tasks, prioritize effectively, and adjust quickly in a dynamic environment.
- Requires strong computer literacy, including navigating various software systems and accurate keyboarding.
- Demands clear and effective verbal and written communication abilities.
- Expected weekly commitment is 40 hours.
- Applicants with criminal records will be considered in compliance with applicable federal, state, and local laws.
