Remote Clinical Utilization Specialist

New England Life Care, Inc.; Boston (MA); Remote; USD 65,000 - 90,000; Full time

Benefits offered by this job

Health insurance

Dental insurance

Vision insurance

Generous 403(b) savings program

Company paid life insurance

Short- and long-term disability

Paid Time Off

Job summary

New England Life Care is seeking a Remote Clinical Review Specialist to conduct utilization management reviews and provide clinical information to confirm patient coverage. This remote role operates on a Monday–Friday 8:30am–5:00pm schedule within the New England region.

The ideal candidate will excel in a fast-paced environment with excellent communication and deductive reasoning skills, and will reside in Maine, Massachusetts, or New Hampshire.

Qualifications

• Medical Assistant certification required.
• MA or LPN preferred.
• 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 managed care environment.
• Experience in utilization review, utilization management, quality review.
• Working knowledge of federal / state fraud and abuse laws required.
• Knowledge of HIPAA Privacy and Security Regulations preferred.

Responsibilities

• Apply clinical skills and expertise in conjunction with established medical criteria, members' eligibility and benefit coverage information, in the review of therapy checklists & specialist drug authorization forms, to ensure high-quality, cost-effective care
• Maintain a thorough and comprehensive understanding of regulations, payer contracts, product lines, NELC policies & procedures.
• Serves as subject matter expert on complex specialty drugs clinical requirements.
• Review clinical documentation for long term government payers to ensure they still meet clinical coverage twice a year. Consulting with the Medical Director for all potential denials that do not meet medical necessity or NELC criteria. The decision for a medically necessary denial is within the Medical Director role
• Act as a liaison between internal and external customers to resolve systems/process issues and ensure we are obtaining signed physician orders from participating MDs for government payers.
• Determine appropriateness and effectiveness of services requested using established medical coverage criteria, guidelines and departmental policies and procedures
• Responsible for timely and comprehensive medical review with concise documentation of pertinent facts, decisions and rationale and facilitation of resolution to requests of "urgently needed, not yet rendered services" in compliance with state regulation.
• Effectively and accurately communicate coverage decisions to members, providers, and medical groups, following timelines established by regulations and accreditation standards.
• Identify and appropriately inform Manager/Supervisor of sensitive or complex cases
• Maintains a thorough and comprehensive understanding of state and federal regulations, accreditation standards and payer contracts to ensure compliance.
• Develop and maintain positive, effective working relationships with Medical Directors, physicians, vendors, managed care offices and other customers
• Maintain confidentiality of member and case information by following Corporate Privacy policies pertaining to protection of member PHI
• Perform other duties as assigned

Education

Medical Assistant certification required

Associate of Arts degree or higher preferred

MA or LPN preferred

Healthcare experience in medical setting

Job description

New England Life Care is seeking a Remote Clinical Review Specialist to conduct utilization management reviews and provide clinical information to confirm patient coverage. This remote role operates on a Monday–Friday 8:30am–5:00pm schedule within the New England region.

The ideal candidate will excel in a fast-paced environment with excellent communication and deductive reasoning skills, and will reside in Maine, Massachusetts, or New Hampshire.