Senior Clinical Review Specialist

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Full Time Professional Canton, MA, US

Salary Range: $24.00 To $25.00 Hourly

New England Life Care (NELC) is one of the fastest growing home infusion therapy companies in New England and is the region’s only non-profit home infusion provider. NELC is a hospital collaborative serving more than 70 hospital systems in Maine, New Hampshire, and Massachusetts. NELC was created by local hospitals to ensure their patients have access to a provider that reflects their commitment to excellence in patient care, quality, and service.

Like our owner hospitals, NELC provides patient focused care.

New England Life Care has and continues to build a diverse, inclusive, and authentic workplace, so if you’re energized by this opportunity, but your experience doesn’t support every qualification in the job posting, we encourage you to apply! You still may be the person we are looking for!

Remote
Clinical Review Specialist opportunity available. This is a remote position with an ideal Monday – Friday from 8:30am until 5:00pm schedule. The ideal candidate for this position will excel in a fast-paced environment, have excellent communication and deductive reasoning skills.

** We are only hiring remote employees for this position that live in Maine, Massachusetts, and New Hampshire.**

The Clinical Review Specialist will conduct regular utilization management reviews and provide clinical information as required in order to confirm coverage for each patient.

• Health insurance
• Vision insurance
• Generous employer-matched 403(b) savings program
• Company paid:
  Life insurance, Short- and long-term disability insurance
• Paid Time Off
• And much more!

• 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,…