Senior Clinical Review Specialist

Job not on LinkedIn

🔥 2 minutes ago

🦞 Maine, New Hampshire, +1 more states – Remote

🦞 Maine – Remote 🗻 New Hampshire – Remote 🍂 Massachusetts – Remote

💵 $24 - $25 / hour

⏰ Full Time

🟠 Senior

🔍🏥 Medical Reviewer

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

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New England Life Care

WebsiteLinkedInAll Job Openings

201 - 500 employees

Founded 1987

🏥 Healthcare

💊 Pharmaceuticals

🤝 Non-profit

Healthcare • Pharmaceuticals • Non-profit

New England Life Care is a nonprofit, mission-driven organization that provides home infusion therapy and specialty pharmacy services. It is affiliated with over 60 premier medical centers across New England and serves communities in Massachusetts, New Hampshire, Maine, and Vermont. New England Life Care focuses on delivering vital infusion therapies to help patients recover at home, emphasizing collaboration and transformation in patient care.

📋 Description

• Conduct regular utilization management reviews and provide clinical information to confirm patient coverage • Apply clinical skills, medical criteria, member eligibility, and benefit coverage information when reviewing therapy checklists and specialist drug authorization forms • Maintain understanding of regulations, payer contracts, product lines, and NELC policies and procedures • Serve as subject matter expert on complex specialty drug clinical requirements • Review clinical documentation for long-term government payers twice yearly to confirm ongoing clinical coverage • Consult with the Medical Director regarding potential denials that do not meet medical necessity or NELC criteria • Liaise between internal and external customers to resolve systems/process issues and obtain signed physician orders • Determine appropriateness and effectiveness of requested services using established criteria, guidelines, and departmental policies • Complete timely, comprehensive medical reviews with concise documentation and resolve urgently needed, not-yet-rendered service requests • Communicate coverage decisions to members, providers, and medical groups within regulatory and accreditation timelines • Identify and inform the Manager/Supervisor of sensitive or complex cases • Maintain compliance with state and federal regulations, accreditation standards, and payer contracts • Develop working relationships with Medical Directors, physicians, vendors, managed care offices, and other customers • Protect member PHI by following Corporate Privacy policies • Perform other duties as assigned

🎯 Requirements

• Medical Assistant certification required • Associate of Arts degree or higher preferred • Healthcare experience in a medical setting required • Prior experience in care coordination, home health or home infusion preferred • Experience in a managed care environment • Experience working with established criteria to determine medical necessity and appropriateness of care • Experience in utilization review, utilization management, or quality review • Working knowledge of federal/state fraud and abuse laws required • Knowledge of HIPAA Privacy and Security Regulations preferred • Excellent verbal and written communication and interpersonal skills • Excellent problem identification and solving skills • Ability to organize and prioritize multiple assignments within workload • Ability to function independently and take independent action within scope of job responsibilities • Competency in computer skills including Microsoft Word, Outlook, and internet • Dependability in attendance and job performance required

🏖️ Benefits

• Career Ladder • Health insurance • Dental insurance • Vision insurance • Generous employer-matched 403(b) savings program • Company paid life insurance • Company paid short- and long-term disability insurance • Paid Time Off