Pacer Staffing LLC

Clinical Review Manager Utilization Management

Pacer Staffing LLC United States
Pacer Staffing LLC

Clinical Review Manager Utilization Management

Pacer Staffing LLC United States
2 months ago 36 applicants

See who Pacer Staffing LLC has hired for this role

Job Title: Clinical Review Manager Utilization Management

Duration: 6 months

Location: Remote

Shift: 8:00am – 5:00pm

License

Job Qualifications

  • Registered Nurse (RN) with active license in the state of Tennessee or hold a license in the state of their residence if the state is participating in the Nurse Licensure Compact Law.

Experience

  • 3 years - Clinical experience required.

Skills\Certifications:

  • Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
  • Working knowledge of URAC, NCQA and CMS accreditations
  • Must be able to work in an independent and creative manner.
  • Excellent oral and written communication skills
  • Strong interpersonal and organizational skills
  • Ability to manage multiple projects and priorities.
  • Adaptive to high pace and changing environment.
  • Customer service oriented
  • Superior interpersonal, client relations and problem-solving skills
  • Proficient in interpreting benefits, contract language specifically symptom-driven, treatment driven, look back periods, rider information and medical policy/medical review criteria.

Responsibilities

Job Description Summary:

  • Perform comprehensive clinical review of requested services utilizing clinical criteria, received through various mechanisms.

Job Responsibilities

  • Initiate referrals to ensure appropriate coordination of care.
  • Seek the advice of the Medical Director when appropriate, according to policy.
  • Assists non-clinical staff in performance of administrative reviews.
  • Performing comprehensive provider and member appeals, denial interpretation for letters, retrospective claim review, special review requests, and UM pre-certifications and appeals, utilizing medical appropriateness criteria, clinical judgement, and contractual eligibility.
  • Weekend work required as needed.
  • Must be able to pass Windows navigation test.
  • Testing/Assessments will be required for Digital positions.

Comments/Special Instructions

  • Active RN license required with 3+ years of clinical experience.
  • Must have worked with EMR as well as have customer service experience on the phone.
  • Must have strong computer and technical skills.
  • Must be flexible to work some weekends.

  • Seniority level

    Mid-Senior level

  • Employment type

    Full-time

  • Job function

    Health Care Provider

  • Industries

    Staffing and Recruiting

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