Company Statement
For the last 80 years, EmblemHealth has been taking care of New York’s heart and soul, its people. Today, health care is more complex than ever. That’s why we’re at the forefront of change. We work alongside our customers to offer access to high-quality, affordable care, help navigate the health care experience, and make good health achievable; because everyone deserves to be taken care of. We deliver on our mission every day by living our values with our colleagues, members, clients and partners. It begins with caring and respecting all those we work with. We believe a culture of diversity and inclusion is vital to serve our unique and diverse customers. We seek for continues improvement and innovation and believe being agile and nimble is our advantage. We bring a strong sense of partnership to every relationship – internally and externally. The EmblemHealth family of companies offers competitive health, welfare, and retirement benefits as well as incentive pay plans and more.
Clinical Reviewer
Responsible for conducting clinical reviews on both standard and expedited appeals, providing comprehensive clinical summaries to the Medical Directors for decisions. Responsible for managing timeframes on expedited appeals, ensuring effectuation and verbal notice is completed in a timely manner. Supports the unit goals and objectives.
Responsibilities:
Utilizes MCG Criteria, CMS Guidelines, medical and administrative policies to evaluate medical necessity of requested service, applying sound clinical judgement.
Reviews clinical cases and formulates responses for Grievance and Appeals. For expedited appeals, monitor timeliness of effectuation and verbal notice. Effectively communicates verbally and in writing all decisions in a timely and professional manner.
Prepares and presents clinical detail to the Medical Director for final case determination in accordance with regulation and department policy.
Ensures internal and regulatory time frames are met (i.e. determination, effectuation, notice).
Utilizes the member’s contract to determine coverage eligibility.
Regular attendance is an essential function of the job. Performs other duties as assigned or required.
Qualifications:
Strong clinical knowledge
Strong organizational skills
Ability to meet deadlines
Good communication skills
Good writing skills
Must be a Registered Nurse or LPN licensed in the State of New York and Connecticut with 3 - 5 years of clinical experience. Prior managed care experience preferred
Knowledge of ICD-9 and CPT Codes
CPC preferred
EEOC Statement
We are committed to leveraging the diverse backgrounds, perspectives and experiences of our workforce to create opportunities for our people and our business. We are an equal opportunity/affirmative action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or any other characteristic protected by law.
Sponsorship Statement
Depending on factors such as business unit requirements, the nature of the position, cost and applicable laws and regulations, EmblemHealth may provide work visa sponsorship for certain positions.