LI
Care Review Clinician I
LanceSoft Inc
🇺🇸 United States
Remote
2 weeks ago
- prior authorization
- RN License
2 weeks ago
Not enough detail in this posting to match
Schedule:Â Varies Sunday-Saturday 6am-9pm PST
Location: Remote, CA
Duration: 03+ Months
Day to Day Responsibilities:
Medical necessity clinical review or services requiring prior authorization
Must Have Requirements:
Health Plan or IPA experience performing prior authorization review, CA RN license
KNOWLEDGE/SKILLS/ABILITIES:
•Assesses services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.
•Analyzes clinical service requests from members or providers against evidence based clinical guidelines.
•Identifies appropriate benefits and eligibility for requested treatments and/or procedures.
•Conducts prior authorization reviews to determine financial responsibility for ***care and its members.
•Processes requests within required timelines.
•Refers appropriate prior authorization requests to Medical Directors.
•Requests additional information from members or providers in consistent and efficient manner.
•Makes appropriate referrals to other clinical programs.
•Collaborates with multidisciplinary teams to promote Care Model
•Adheres to UM policies and procedures.
•Occasional travel to other offices or hospitals as requested, may be required. This can vary based on the individual State Plan.
Care Review Clinician I · LanceSoft Inc