Clinical Review Manager Utilization Management
Clinical Review Manager Utilization Management
Pacer Staffing LLC
United States
See who Pacer Staffing LLC has hired for this role
Duration: 6 months
Location: Remote
Shift: 8:00am – 5:00pm
License
Job Qualifications
- Registered Nurse (RN) with active license in the state of Tennessee or hold a license in the state of their residence if the state is participating in the Nurse Licensure Compact Law.
- 3 years - Clinical experience required.
- Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
- Working knowledge of URAC, NCQA and CMS accreditations
- Must be able to work in an independent and creative manner.
- Excellent oral and written communication skills
- Strong interpersonal and organizational skills
- Ability to manage multiple projects and priorities.
- Adaptive to high pace and changing environment.
- Customer service oriented
- Superior interpersonal, client relations and problem-solving skills
- Proficient in interpreting benefits, contract language specifically symptom-driven, treatment driven, look back periods, rider information and medical policy/medical review criteria.
Job Description Summary:
- Perform comprehensive clinical review of requested services utilizing clinical criteria, received through various mechanisms.
- Initiate referrals to ensure appropriate coordination of care.
- Seek the advice of the Medical Director when appropriate, according to policy.
- Assists non-clinical staff in performance of administrative reviews.
- Performing comprehensive provider and member appeals, denial interpretation for letters, retrospective claim review, special review requests, and UM pre-certifications and appeals, utilizing medical appropriateness criteria, clinical judgement, and contractual eligibility.
- Weekend work required as needed.
- Must be able to pass Windows navigation test.
- Testing/Assessments will be required for Digital positions.
- Active RN license required with 3+ years of clinical experience.
- Must have worked with EMR as well as have customer service experience on the phone.
- Must have strong computer and technical skills.
- Must be flexible to work some weekends.
-
Seniority level
Mid-Senior level -
Employment type
Full-time -
Job function
Health Care Provider -
Industries
Staffing and Recruiting
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