Clinical Review Analyst

Job ID: FIW-1018086 Description:

HCSC is committed to diversity in the workplace and to providing equal opportunity and affirmative action to employees and applicants.We are an Equal Opportunity Employment / Affirmative Action employer dedicated to workforce diversity and a drug-free and smoke-free workplace. Drug screening and background investigation are required, as allowed by law. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status.

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BASIC FUNCTION:

This position is responsible for performing clinical retrospective review in accordance with the application of medical necessity criteria using the Medical Management software system and M & R criteria (nationally accredited criteria set); consulting with physician advisors, providers, and members to assist them in their understanding of the requirements of their health plan and to ensure proper information is recorded in the case summary; assisting members in their requests for clinical waivers, inclusive of the identification of available providers/services within their area; explaining the appeal process to members/providers for denial of services requested in accordance with legislation and accreditation standards; and assisting with the claims adjudication process.

JOB REQUIREMENTS:

• Registered Nurse (RN) with unrestricted, current license in state of operations.
• 3 years of clinical practice experience.
• 1 year health insurance/managed care experience.
• Knowledge of accreditation standards/legislation, i.e. URAC, NCQA.
• PC and database experience.
• Verbal and written communication skills.
• Organizational skills and prioritization skills.

PREFERRED JOB REQUIREMENTS:

• Knowledge of BCBSTX or BCBSIL Medical Management Policies and Procedures.

HCSC is committed to diversity in the workplace and to providing equal opportunity and affirmative action to employees and applicants. We are an Equal Opportunity Employment / Affirmative Action employer dedicated to workforce diversity and a drug-free and smoke-free workplace. Drug screening and background investigation are required, as allowed by law. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status.

Requirements: Expertise Nursing Job Type Full-Time Regular Location IL - Chicago, TX - Richardson