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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. Reviews 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. Maintains current departmental standards related to productivity. Trains in clinical certification, utilization management, URAC and NCQA principles, policies, and procedures. Prepares program correspondence as needed. Serves as a resource for members calling for assistance. Makes outbound calls as required. Refers provider and member complaints, and appeals to appropriate departments. Maintains patient confidentiality in accordance with eviCore standards established in compliance with HIPAA and State regulations. Provides outstanding customer service ensuring callers receive the highest possible service. Runs and analyzes reports to ensure all tasks are completed in a timely fashion and meet regulatory requirements. Assists team members in departmental chats, by phone and in person. Acts as training assistant when assigned. Assist team members with questions, participates in team meetings. Can be assigned to projects to support the department as needed. Performs related duties as required.
Current, unrestricted license as RN in state of primary residence or appropriate compact state.
Must have at least 1 year of acute care, managed care, ER or ICU experience.
Must be able to sit through shift, demonstrate advanced proficiency in MS Office applications. Excellent communication skills both verbal and written; excellent problem solving and customer service skills are required. Must be self directed and highly motivated with an ability to multi-task. Excellent computer skills. Must type at least 30 WPM. Must be able to hear and speak on the phone for an entire shift
The eviCore team is committed to making a positive impact on healthcare. We have brought together experts from around the country to create a talented team of individuals who connect the dots between the patient, provider, and plan. We work together every day in an honest, flexible, empathetic, and collaborative environment to generate the change we seek for healthcare. We use the same factors in ...considering future team members. We are looking for candidates who emulate our core values (flexibility, collaboration, integrity, and empathy) and will integrate their intelligence and insights to prompt more focused action and improved results.Mission– To help those we serve navigate the healthcare system, find the right care path, and enable the best outcomes.Vision– To improve the healthcare system and people’s lives through innovative medical benefits solutionsValues– Integrity, Flexibility, Empathy, and Collaboration