About the Role
This role involves conducting clinical reviews to support appropriate use of healthcare services, ensuring patient needs are met while aligning with regulatory and insurance standards.
Responsibilities
- Evaluate patient cases to ensure appropriate use of medical services
- Review treatment plans for clinical necessity and compliance
- Collaborate with healthcare providers to coordinate care decisions
- Support timely authorization of medical procedures and referrals
- Ensure adherence to regulatory and insurance guidelines
- Document clinical assessments and decisions accurately
- Respond to provider inquiries regarding utilization criteria
- Maintain up-to-date knowledge of clinical guidelines and policies
- Participate in quality improvement initiatives
- Assist in streamlining care management workflows
Nice to Have
- Certification in case or care management (e.g., CCM, ACM)
- Experience with Medicare and Medicaid populations
- Background in primary care or chronic disease management
- Prior work in a remote or telehealth environment
Benefits
- Medical, dental, and vision insurance
- Retirement savings plan with employer contributions
- Paid time off and holidays
- Employee assistance program
- Professional development opportunities
- Flexible spending accounts
Compensation
Not specified
Work Arrangement
Remote
Team
Part of a healthcare support team focused on clinical operations and patient care coordination
Shift Availability
Candidates must be available for either the 10:30 a.m.–7:00 p.m. or 11:30 a.m.–8:00 p.m. Eastern Time shift, Monday through Friday.
Remote Work Requirements
Applicants must have a quiet, dedicated workspace and reliable high-speed internet to perform duties effectively from home.
Not available
