Pay Range: $38/hr-$41/hr

About the Role:

• We are seeking a Clinical Reviewer to complete clinical reviews for inpatient services.
• The role involves verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations to ensure members reach desired outcomes through integrated delivery of care across the continuum.
• The ideal candidate will contribute to the overarching strategy to provide quality and cost-effective member care.

Responsibilities: -

• Assess services for members to ensure optimum outcomes, cost-effectiveness, and compliance with all state/federal regulations and guidelines. 
• Analyze clinical service requests from members or providers against evidence-based clinical guidelines.
• Identify appropriate benefits, eligibility, and expected length of stay for requested treatments and/or procedures.
• Conduct reviews to determine prior authorization/financial responsibility for client and its members.
• Process requests within required timelines.
• Refer appropriate cases to medical directors (MDs) and present them in a consistent and efficient manner.
• Request additional information from members or providers as needed.
• Make appropriate referrals to other clinical programs.
• Attend Rounds.
• Collaborate with multidisciplinary teams to promote the care model.
• Adhere to utilization management (UM) policies and procedures.

Education Qualification: -

• At least 2 years of experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience.

Required Skills: -

• Ability to prioritize and manage multiple deadlines.
• Excellent organizational, problem-solving, and critical-thinking skills.
• Strong written and verbal communication skills.
• Proficiency in MS Office suite/applicable software program(s).
• Knowledge of nationally recognized criteria
• UM/UR experience.
• Preferred qualifications include Certified Professional in Healthcare Management (CPHM) and recent hospital experience in an intensive care unit (ICU) or emergency room.

Benefits

The Company offers the following benefits for this position, subject to applicable eligibility requirements: medical insurance, dental insurance, vision insurance, 401(k) retirement plan, life insurance, long-term disability insurance, short-term disability insurance, paid parking/public transportation, paid time off, paid sick and safe time, hours of paid vacation time, weeks of paid parental leave, and paid holidays annually – as applicable.