Manager

EXL; India; On-site; INR 1,200,000 - 2,400,000; Full time

Job summary

EXL is seeking a Clinical Reviewer to work with Regional Medical Directors to make evidence-based decisions on requested cases for IP/OP, and to conduct retrospective clinical reviews in line with CMS criteria while contacting providers as needed.

The role involves reviewing cases, determining medical necessity, and coordinating peer-to-peer discussions with physicians to ensure alignment with plan coverage guidelines.

Qualifications

• Bachelor's degree in a relevant field with 6–8 years of relevant experience.

Responsibilities

• Performs clinical review of cases and makes a decision to approve or deny based on plan coverage and guidelines.
• Pends / refers cases for further review by Regional Medical Directors for medical necessity and coordinates peer-to-peer reviews when applicable.

Skills

Clinical decision making

Evidence based review

Provider communication

Education

Bachelor's Degree

Job description

Job Description:

Works with Regional Medical Directors to make sound, evidence based clinical decisions regarding the requested cases (treatments and procedures) for IP/OP and performs retrospective clinical reviews utilizing criteria set forth by the client and Medicare (CMS-Centers for Medicare and Medicaid Services) and perform outbound calls to providers.

Responsibilities

Performs clinical review of cases received from the specialist team or other departments within CCR, determines if additional clinical information if required, makes a clinical decision to approve or deny a case based on plan coverage, criteria and / or guidelines or pend / refer it to the Regional Medical Directors for further review for medical necessity, and coordinates a peer to peer (doctor to doctor case discussion) review as applicable.

Qualifications

Bachelor Degree in relevant field with 6- 8 years of relevant experience