Nurse Clinical Care Reviewer | ProSphere Tek | Remote (US)

Nurse Clinical Care Reviewer | ProSphere Tek | Remote (US)

Remote US
Application ends: July 29, 2024
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Job Description

Nurse Clinical Care Reviewer

Location: US-Remote


This position will be filled by a nurse to serve as a Nurse Clinical Care Reviewer for the Medical Benefits and Certifications Unit. The Nurse Clinical Care Reviewer will participate in all aspects of medical benefit decisions for responders and survivors of the 9/11 attacks. These decisions include, but are not limited to; certification decisions for new health conditions and health care benefit prior authorization requests.
In addition, the Nurse Clinical Care Reviewer may provide recommendations for services that are cost-effective and in compliance with Program regulations and guidelines. The Nurse Clinical Care Reviewer will make recommendations based on Program statutes, policy, collaboration with experts, clinical research and their own clinical and professional judgement and analytical skills. Additional duties include managing complex program deliverables, analyzing and manipulating medical claims data and collaborating with occupational health subject matter experts. The Nurse Clinical Care Reviewer will interface with clinicians, medical administrators, and a diverse set of federal and contract staff. The work requires excellent organizational, verbal and written communication skills, attention to detail, innovative problem solving, and self-initiation. The WTC Health Program leadership and management team will provide guidance commensurate with the Nurse Clinical Care Reviewer ‘s level of duties.

Essential Functions and Job Responsibilities

• Reviews and makes recommendations on requests for certification of health conditions, in alignment with Program guidelines and policies, permitting member access to treatment benefits.
• Analyzes and makes recommendations in writing against Program regulations and guidelines and evidence-based clinical guidelines for clinical service requests from health care providers.
• Appropriately prioritizes and tracks all certification and prior authorization requests, reviewing them for completeness and alignment with Program policy and requirements; makes recommendations to approve or deny these requests using clinical and professional judgement and analytical skills within required timeframe.
• Collaborates with subject matter experts when making decisions and recommendations.
• Requests additional information from providers in a consistent and efficient manner with superior customer service.
• Liaises with denial and appeal coordinators for denial decisions. Creates denial letters and collaborates with the Office of General Counsel to review.
• Educates clinical center staff/providers regarding certification requests, authorization requirements, eligibility guidelines, and documentation requirements.
• Provides analytic support of cost and utilization reporting.
• Understands complex legislative, regulatory, and/or policy guidance for use in executing daily activities.
• Monitors, coordinates and tracks multi-functional program deliverables, ensuring deadlines are met.

The work entails both clinical and administrative aspects of health care delivery within a federal managed care system and involves collaboration with both clinicians and medical administrators. The WTC Health Program Medical Benefits and Certifications Unit Chief will provide support and guidance to the contractor in the performance of these deliverables.

Minimum Requirements

Special Considerations or Requirements:
The knowledge, skills and abilities are specific in this task area and shall include:
Completion of an accredited Registered Nurse (RN) Program preferred OR a Bachelor’s Degree in a healthcare field, such as social work or clinical counselor may be considered.

Required Experience
• 1-3 years’ experience working in a health care or managed care setting.
• Experience working in a managed care/clinical setting or with payer claims data in a health plan preferred, but not required.
• Proficient in Microsoft Office Suites, including Excel, Outlook, SharePoint; Proficiency with MS Windows Office programs, including MS Word, Excel, and Outlook to create complex documents, manage schedules, and analyze data.

Company Benefits

PSI offers full-time, benefits eligible employees a competitive total compensation package that includes paid leave, and options for employer sponsored group medical, dental, vision, short-term and long-term disability, life insurance, AD&D coverage, legal services, identity theft, and accident insurance. Flexible spending account and health saving account options offer pre-tax savings for qualified medical, dental, and vision expenses. The company sponsored 401(k) retirement plan has an employer contribution match that is immediately vested. We invest in the professional growth of our employees through professional courses, certifications, and tuition reimbursement programs.

EEO Commitment

It is company policy to promote equal employment opportunities. All personnel decisions, including, but not limited to, recruiting, hiring, training, promotion, compensation, benefits, and termination, are made without regard to race, color, religion, age, sex, sexual orientation, pregnancy, gender identity, genetic information, national origin, citizenship status, veteran status, protected veteran status, disability, or any other characteristic protected by applicable federal, state, or local law.