CareCore National Registered Nurse - Clinical Reviewer - Bluffton, SC in Bluffton, South Carolina
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Responsible for all clinical certification activities, which include but are not limited to evaluating telephone, fax or WEB requests for authorization of clinical services from physician offices/and or imaging centers, comparing requests against established clinical protocols and authorizing services or referring requests for expert clinical review as appropriate. Reviews clinical information submitted by providers to appropriate criteria and standards and makes decision to issue a review determination or to refer to physician review if criteria are not met. Maintains current departmental standards related to productivity. Trains in clinical certification, utilization management, URAC and NCQA principles, policies, and procedures. Prepares program correspondence as needed. Serves as a resource for members calling for assistance. Makes outbound calls as required. Refers provider and member complaints, and appeals to appropriate departments. Maintains patient confidentiality in accordance with eviCore standards established in compliance with HIPAA and State regulations. Provides outstanding customer service ensuring callers receive the highest possible service. Runs and analyzes reports to ensure all tasks are completed in a timely fashion and meet regulatory requirements. Assists team members in departmental chats, by phone and in person. Acts as training assistant when assigned. Assist team members with questions, participates in team meetings. Can be assigned to projects to support the department as needed. Performs related duties as required.
THIS POSITION IS LOCATED IN Bluffton, SC REMOTE POSSIBILITY AFTER 90 DAYS.
Minimum Experience Required
Current, unrestricted license as LPN/RN in South Carolina.
Must have at least 1 year of acute care, managed care, ER or ICU experience.
Minimum Experience: Must have at least 1 year of acute care, managed care, ER or ICU experience.
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eviCore healthcare is an Equal Opportunity Employer