Telephonic Nurse Clinical Reviewer -EviCore-RemoteFull time RN Role- Remote Monday- Friday 12:30pm-9:00 pm EST (Required Shift)Start Date: Monday, September 14thShift for this role is Monday- Friday 12:30pm-9:00 pm EST.
Start time may vary based on your local time zone.
The first 7 weeks of employment will be day shift for training purposes.
In the future, shift may vary based on business need to any 8 hour shift between the hours of 7am in your local time zone – 10 pm EST, Monday – Friday.
There are no scheduled absences allowed during training for this role.
The Clinical Reviewer will be 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.
Know and understand complex case specialties and case reviews.
Review 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.
 Maintain current departmental standards related to productivity.
 Train in clinical certification, utilization management, URAC and NCQA principles, policies, and procedures.
 Prepare program correspondence as needed.
 Serve as a resource for members calling for assistance.
Make outbound calls as required.
 Refer provider and member complaints, and appeals to appropriate departments.
 Maintain patient confidentiality in accordance with EviCore standards established in compliance with HIPAA and State regulations.
 Provide outstanding customer service ensuring callers receive the highest possible service.
 Run and analyze reports to ensure all tasks are completed in a timely fashion and meet regulatory.