Clinical Resource Coordinator
6 giorni fa
We are seeking a skilled Clinical Resource Coordinator to join our team at US Tech Solutions.
The successful candidate will be responsible for reviewing and evaluating medical eligibility regarding benefits and clinical criteria by applying clinical expertise, administrative policies, and established clinical criteria to service requests or provides health management program interventions.
This role requires a working knowledge of word processing software, quality improvement processes, and demonstrated ability with these activities. The ideal candidate will have good judgment skills, demonstrated customer service, organizational, and presentation skills, as well as proficiency in spelling, punctuation, and grammar skills.
Key Responsibilities:
- Reviews and evaluates medical or behavioral eligibility regarding benefits and clinical criteria
- Provides health management program interventions
- Utilizes clinical proficiency, claims knowledge/analysis, and comprehensive knowledge of healthcare continuum to assess, plan, implement, coordinate, monitor, and evaluate medical necessity, options, and services required to support members in managing their health, chronic illness, or acute illness
- Maintains accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits
Requirements:
- 4 years recent clinical experience in a defined specialty area, such as oncology, cardiology, neonatology, maternity, rehabilitation services, mental health/chemical dependency, orthopedic, general medicine/surgery
- OR 4 years utilization review/case management/clinical/or combination experience; 2 of 4 years must be clinical
- Active, unrestricted RN licensure from the United States and in the state of hire, OR active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC)
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