ncqa accreditation specialist

Alliance Health Plan

<div>The NCQA Quality &amp; Accreditation Analyst serves as the project management lead and subject matter expert for assigned NCQA standard areas and manages the assessment of related business functions for corresponding departments within the scope of NCQA standards (e.g. Provider and Member Services, Utilization Management, Population Health, Care Management, Provider Network, Member and Provider Communications, Delegation Oversight) to support high-quality performance and ensure successful NCQA Accreditation process. Additionally, this role supports the Continuous Quality Improvement Committee.

This position is fulltime remote. Selected candidate must reside in North Carolina. Some travel for onsite meetings at the Home office (Morrisville, NC) may be required.

Responsibilities &amp; Duties

Implement and Monitor Accreditation Workplan
<ul>
<li>Project lead for assigned NCQA standard categories to achieve and maintain Health Plan Accreditation with LTSS distinction and any additional accreditations Alliance Health pursues</li>
<li>Identify gaps and risks and provide regular status reports from NCQA tracker to leadership</li>
<li>Serve as lead for NCQA Accreditation reviews for assigned standard categories by gathering all necessary documents and information from business areas, managing timely document submissions to NCQA, facilitating NCQA requests for additional information, and coordinating onsite review activities</li>
<li>Review and update policies and procedures, reports, materials, and files for completeness, accuracy, and compliance with NCQA Standards</li>
<li>Maintain ongoing collection and tagging relevant policies/procedures, reports, materials, and files as appropriate</li>
<li>Participate in Delegation Oversight and audits as appropriate</li>
</ul>
Drive Organizational Accreditation Efforts
<ul>
<li>Provide technical support and education to staff regarding NCQA Health Plan Accreditation and LTSS Distinction Standards and supporting documentation</li>
<li>Assess business area functions against current and upcoming NCQA standards and identify potential performance gaps and associated risks and update NCQA tracker upon release of new/updated standards</li>
<li>Serve as the accreditation subject matter expert within organizational wide, cross-functional, and multi-disciplinary teams to bring each business area to a state of readiness</li>
<li>Identify and facilitate business area process improvements via means such as policies, workflows, and processes; follow-up to ensure improved outcomes</li>
<li>Coordinate and collaborate with cross-departmental teams to identify and implement organization-wide strategic initiatives that support quality performance</li>
<li>Communicate reporting due dates and reminders to business leads and leadership as appropriate</li>
<li>Maintain clear status updates regarding NCQA Readiness on NCQA Tracker, communicating risks as appropriate</li>
<li>Lead the compliance review for non-clinical standards</li>
<li>Partner with other departments to align documentation, policies, and practices with NCQA standards</li>
<li>Conduct standards reviews, present findings to departments and leadership</li>
<li>Develop and communicate compliance recommendations</li>
</ul>
Support Continuous Quality Improvement Committee
<ul>
<li>Review and maintain documentation, agendas, minutes, follow up items</li>
<li>Ensure documentation meets NCQA compliance</li>
<li>Track and remeasure impact of interventions with business leads</li>
<li>Conduct orientation with new Committee members</li>
</ul>
Minimum Requirements

Education &amp; Experience

Required:

Bachelor&rsquo;s degree in healthcare, human services, public health administration, nursing, business, or related field and five (5) years of managed care with knowledge and practical experience health care quality or NCQA Health Plan accreditation processes and requirements.

Preferred:

Experience with NCQA Accreditation standards.

Knowledge of regulatory reporting, compliance requirements, and auditing procedures.

Project management.

Knowledge, Skills, &amp; Abilities
<ul>
<li>Knowledge of NCQA accreditation processes and standards</li>
<li>Knowledge and understanding of federal and state regulations</li>
<li>Project Management</li>
<li>Excellent communication skills (written and verbal).</li>
<li>Interpersonal skills which are effective, respectful, and sensitive to a diverse and multicultural population of children, families, and co-workers,</li>
<li>Problem-solving, mediation, and conflict resolution skills</li>
<li>Teamwork and collaboration skills</li>
<li>Microsoft Project, Excel, Word (Edits and Tracking), and PowerPoint skills</li>
<li>Facilitation skills</li>
</ul>
Salary Range

$77,868 - $99,282/Annually

Exact compensation will be determined based on the candidate's education, experience, external market data and consideration of internal equity.

An excellent fringe benefit package accompanies the salary, which includes:
<ul>
<li>Medical, Dental, Vision, Life, Long Term Disability</li>
<li>Generous retirement savings plan</li>
<li>Flexible work schedules including hybrid/remote options</li>
<li>Paid time off including vacation, sick leave, holiday, management leave</li>
<li>Dress flexibility</li></ul></div>

NCQA Quality & Accreditation Analyst (Full-Time Remote, North Carolina Based)

Whitney M. Young Jr. Health Center, Inc.

<div>Description:

GENERAL RESPONSIBILITIES:
The Onboarding Specialist guides new hires through a seamless onboarding process, ensuring their successful integration into our organization. They manage the end-to-end process, including paperwork, system setups, orientation and training.
SPECIFIC RESPONSIBILITIES:<ul><li>
Acts as the central point of contact for the Human Resources Office, including walk-ins, calls-ins, and correspondences from employees, managers, and third parties.</li><li>
Coordinates the new hire onboarding process including, but not limited to, accurate completion of the pre-employment background checks, health clearances and appropriate paperwork</li><li>
Works closely with the HR team and other departments to ensure a smooth and positive onboarding experience</li><li>
Ensures compliant Paylocity onboarding for new hires, including I-9 and E-Verify processing</li><li>
Assists with the coordination, scheduling/notification of new employee orientation, as well as presenting on HR topics.</li><li>
Reviews and responds to employees regarding policy, procedure and other human resources related inquiries.</li><li>
Prepares and updates employee security/access badges</li><li>
Maintains confidential personnel files and conducts file audits to ensure compliance with local, state and federal regulations, i.e. JCAHO, OASAS, NYSDOH, Affirmative Action, etc.</li><li>
Tracks employee data to ensure timely submission of employee physicals, BLS, professional licenses, Infection Control certifications, provider contracts.</li><li>
Processes employee benefits paperwork.</li><li>
Assists employees with completing benefits paperwork and resolving insurance issues.</li><li>
Performs general office duties including, word processing, typing, preparing correspondence, filing, photocopying, handling mail and other office machines.</li><li>
Supports recruiting efforts by following-up on leads and guiding candidates through hiring process, responding to job inquiries from internal and external candidates, doing pre-screening of applicants for some positions and attend job fairs</li><li>
Supports Managers with policy interpretation and administration, as directed.</li><li>
Demonstrates excellence in both internal and external customer service.</li><li>
Understands and is able to effectively communicate HIPAA compliance, corporate compliance and client confidentiality.</li><li>
Ensures and/or remains in compliance with local, state, and federal regulation, i.e. DHHS HRSA and NYSDOH, and all accreditation standards (e.g. Joint Commission and NCQA-PCMH).</li><li>
Adheres to the National Patient Safety Goals as defined by the Joint Commission and Whitney M. Young Jr. Health Center.</li><li>
Completes other duties as assigned.</li></ul>
Requirements:

MINIMUM QUALIFICATIONS:
Associate degree with a minimum of one (1) year Human Resources experience with progressive responsibilities, or High School Diploma with at least three (3) years of Human Resources experience. Computer proficiency in Microsoft Office Suite and Adobe. Excellent verbal, written, and interpersonal communication skills.
PREFERRED QUALIFICATIONS:
Bachelor&rsquo;s degree with course work in business administration, human resources, or comparable field. Ability to work with senior management. Proficient in HRIS platform. Experience in a healthcare setting. At least four (4) years of progressive experience in a business environment performing human resource administrative duties. 
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other legally protected status.
Salary range: $24.00 - $27.00 hourly</div>

Onboarding Specialist (Req 101074)

Heritage NY Medical, PC

Job Overview We are seeking a dynamic and detail-oriented Project Manager who will be responsible for overseeing and coordinating operational, administrative, and strategic healthcare projects to support organizational goals, improve workflow efficiency, and enhance patient care operations. This role will ensure projects are implemented successfully, completed within established timelines, and aligned with regulatory and operational standards.The Project Manager will support initiatives related to population health, quality improvement, provider operations, care coordination, compliance, patient engagement, and administrative process improvement. The ideal candidate will possess strong healthcare administrative experience, exceptional organizational skills, and the ability to manage multiple projects in a fast-paced healthcare environment.Responsibilities<ul><li>Lead and manage healthcare administrative and operational projects from initiation through implementation and completion.</li><li>Develop project plans, timelines, workflows, deliverables, and performance tracking tools.</li><li>Coordinate project activities among the clinical operations department, provider offices, operations teams, clinical and non-clinical staff, and management.</li><li>Monitor project progress to ensure timelines, objectives, and organizational goals are achieved.</li><li>Support implementation of healthcare operational initiatives, population health programs, quality improvement activities, and workflow optimization projects.</li><li>Analyze operational processes and identify opportunities for improved efficiency, productivity, patient experience, and regulatory compliance.</li><li>Assist with development and implementation of policies, procedures, and operational standards.</li><li>Prepare reports, dashboards, presentations, meeting summaries, and project status updates for management review.</li><li>Track and monitor key performance indicators (KPIs), quality metrics, patient engagement outcomes, and operational performance data.</li><li>Coordinate meetings, project timelines, training sessions, and follow-up activities related to assigned initiatives.</li><li>Ensure projects remain compliant with CMS, Medicare, Medicaid, HIPAA, NCQA, and organizational requirements.</li><li>Support provider relations and coordination activities with contracted primary care offices and external healthcare partners.</li><li>Assist with implementation and oversight of care gap closure initiatives, preventive health programs, and patient outreach workflows.</li><li>Identify project risks, operational barriers, and workflow challenges and develop corrective action plans.</li><li>Maintain accurate project documentation, records, and communication logs.</li><li>Support audits, compliance reviews, accreditation preparation, and regulatory readiness activities.</li><li>Collaborate with management to prioritize strategic initiatives and organizational goals.</li><li>Maintain confidentiality of patient, provider, and organizational information in accordance with HIPAA regulations.</li><li>Perform additional administrative and operational duties as assigned.</li></ul>Qualifications<ul><li>Bachelor&rsquo;s degree in Healthcare Administration, Business Administration, Public Health, Nursing, or related healthcare field required.</li><li>Master&rsquo;s degree preferred.</li><li>Minimum of 3&ndash;5 years of healthcare administrative, healthcare operations, project management, or population health experience required.</li><li>Experience working within healthcare organizations, managed care, physician practices, Medicaid, Medicare, or value-based care environments strongly preferred.</li><li>Strong understanding of healthcare operations, provider workflows, care coordination, quality initiatives, and regulatory standards.</li><li>Knowledge of CMS, Medicaid, Medicare, NCQA, HIPAA, and healthcare compliance requirements preferred.</li><li>Experience managing healthcare operational projects, process improvement initiatives, and interdisciplinary workflows preferred.</li><li>Excellent organizational, leadership, communication, and problem-solving skills.</li><li>Ability to prioritize multiple projects and manage competing deadlines effectively.</li><li>Strong analytical and reporting skills with attention to detail.</li><li>Proficiency with Microsoft Office Suite, electronic medical records, project management systems, and reporting platforms.</li><li>PMP certification or healthcare project management certification preferred.</li></ul>Pay: $75,000.00 - $90,000.00 per yearBenefits:<ul><li>401(k)</li><li>Dental insurance</li><li>Employee assistance program</li><li>Flexible spending account</li><li>Health insurance</li><li>Paid time off</li><li>Vision insurance</li></ul>Work Location: Hybrid remote in Garden City, NY 11530

Project Manager - Healthcare Operations

Palm Medical Centers

<div>Position Summary: 
The Concurrent Review Nurse is responsible for performing utilization management activities to ensure medical services are delivered effectively, efficiently, and appropriately. This includes reviewing inpatient admissions and ongoing hospital stays to determine medical necessity, appropriateness of care, and length of stay in accordance with clinical guidelines and payer requirements. 
 
Key Responsibilities:<ul><li>
Conduct timely and accurate concurrent reviews of inpatient hospitalizations and other levels of care.</li><li>
Evaluate clinical documentation against evidence-based criteria (e.g., InterQual&reg;, MCG) to determine medical necessity and appropriate level of care.</li><li>
Collaborate with physicians, hospital staff, and insurance companies to coordinate patient care and discharge planning.</li><li>
Communicate utilization review decisions and recommendations to providers and payers.</li><li>
Document all reviews, decisions, and communications in accordance with regulatory and organizational standards.</li><li>
Identify cases requiring escalation or peer review and follow established procedures.</li><li>
Ensure compliance with CMS guidelines, accreditation standards (e.g., NCQA, URAC), and HIPAA.</li><li>
Participate in quality improvement initiatives and departmental meetings</li></ul>
Qualifications: 
 
Education &amp; Licensure:<ul><li>
Registered Nurse (RN) license, active and in good standing, required.</li><li>
Associate or Bachelor&rsquo;s degree in nursing (BSN preferred).</li></ul>
Experience:<ul><li>
Minimum 2 years of clinical experience (e.g., med-surg, critical care).</li><li>
At least 1 year of utilization review, case management, or managed care experience preferred.</li></ul>
Skills &amp; Competencies:<ul><li>
Knowledge of InterQual&reg;, MCG, or other clinical review guidelines.</li><li>
Familiarity with Medicare/Medicaid and commercial insurance regulations.</li><li>
Strong analytical and clinical judgment skills.</li><li>
Effective communication and negotiation skills.</li><li>
Proficient with electronic medical records (EMRs) and utilization review platforms.</li><li>
Detail-oriented with excellent organizational skills.</li></ul>
Work Environment:<ul><li>
Remote</li></ul> 
Palm Primary Care is an equal opportunity employer that is committed to diversity and inclusion in the workplace. We prohibit discrimination and harassment of any kind based on race, color, sex, religion, sexual orientation, national origin, disability, genetic information, pregnancy, or any other protected characteristic as outlined by federal, state, or local laws. 
 
This policy applies to all employment practices within our organization, including hiring, recruiting, promotion, termination, layoff, recall, leave of absence, compensation, benefits, training, and apprenticeship. Palm Primary Care makes hiring decisions based solely on qualifications, merit, and business needs at the time.
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Concurrent Review Nurse

Brighton Health Plan Solutions

<div>
 
 About The Role
 
 
 
 BHPS provides Utilization Management services to its clients. The Utilization Management Nurse performs medical necessity and benefit review requests in accordance with national standards, contractual requirements, and a member&rsquo;s benefit coverage while working remotely.
 
 
 
 Primary Responsibilities
 
 
 
 <ul>
 <li>
 Performs clinical utilization reviews using evidenced based guidelines, policies and nationally recognized clinical criteria and internal policies/procedures
 </li>
 <li>
 Identifies potential Third-Party Liability and Coordination of Benefit Cases and notifies appropriate parties/departments
 </li>
 <li>
 Collaborates with healthcare partners to ensure timely review of services and care
 </li>
 <li>
 Provides referrals to Case management, Disease Management, Appeals &amp; Grievances, and Quality Departments as needed
 </li>
 <li>
 Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards
 </li>
 <li>
 Identifies potential quality of care issues, service or treatment delays and intervenes as clinically appropriate
 </li>
 <li>
 Triages and prioritizes cases and other assigned duties to meet required turnaround times
 </li>
 <li>
 Prepares and presents cases to Medical Director (MD) for medical director oversight and necessity determinations
 </li>
 <li>
 Communicates determinations to providers and/or members in compliance with regulatory and accreditation requirements
 </li>
 <li>
 Duties as assigned
 
 
 </li>
 </ul>
 
 Essential Qualifications
 
 
 
 <ul>
 <li>
 Current Licensed Practical Nurse (LPN) with state licensure. Must retain active and unrestricted licensure throughout employment
 </li>
 <li>
 Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
 </li>
 <li>
 Must be able to work independently
 </li>
 <li>
 Must be detail oriented and have strong organizational and time management skills
 </li>
 <li>
 Adaptive to a high pace and changing environment- flexibility in assignment
 </li>
 <li>
 Proficient in Utilization Review process including benefit interpretation, contract language, medical and policy review
 </li>
 <li>
 Proficient in MCG and CMS criteria sets
 </li>
 <li>
 Experience with both inpatient and outpatient reviews including Behavioral Health, DME, Genetic Testing, Clinical Trials, Oncology, and/or elective surgical cases preferred
 </li>
 <li>
 Working knowledge of URAC and NCQA
 </li>
 <li>
 2+ years&rsquo; experience in a UM team within managed care setting
 </li>
 <li>
 3+ years&rsquo; experience in clinical nurse setting preferred
 </li>
 <li>
 TPA Experience preferred
 
 
 </li>
 </ul>
 
 About
 
 
 
 At Brighton Health Plan Solutions, LLC, our people are committed to the improvement of how healthcare is accessed and delivered. When you join our team, you&rsquo;ll become part of a diverse and welcoming culture focused on encouragement, respect and increasing diversity, inclusion and a sense of belonging at every level. Here, you&rsquo;ll be encouraged to bring your authentic self to work with all of your unique abilities.
 
 
 Brighton Health Plan Solutions partners with self-insured employers, Taft-Hartley Trusts, health systems, providers as well as other TPAs, and enables them to solve the problems facing today&rsquo;s healthcare with our flexible and cutting-edge third-party administration services. Our unique perspective stems from decades of health plan management expertise, our proprietary provider networks, and innovative technology platform. As a healthcare enablement company, we unlock opportunities that provide clients with the customizable tools they need to enhance the member experience, improve health outcomes and achieve their healthcare goals and objectives. Together with our trusted partners, we are transforming the health plan experience with the promise of turning today&rsquo;s challenges into tomorrow&rsquo;s solutions.
 
 
 Come be a part of the Brightest Ideas in Healthcare&trade;.
 
 
 
 Company Mission
 
 
 
 Transform the health plan experience &ndash; how health care is accessed and delivered &ndash; by bringing outstanding products and services to our partners.
 
 
 
 Company Vision
 
 
 
 Redefine health care quality and value by aligning the incentives of our partners in powerful and unique ways.
 
 
 Powered by JazzHR
 
 
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</div>

Utilization Management Nurse

Centene Corporation

<div>
 You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.
 
 
 
 RN Strongly Preferred - Compact RN License Required
 
 
 
 
 100% Remote
 
 
 
 
 Business Hours are 8a - 6p CST. Shifts include one day on the weekend
 
 
 
 
 Position Purpose
 
 Performs clinical reviews needed to resolve and process appeals by reviewing medical records and clinical data to determine medical necessity for services in accordance with policies, guidelines, and National Committee for Quality Assurance (NCQA) standards.
 
 
 <ul>
 <li>
 Prepares case reviews for Medical Directors by researching the appeal, reviewing applicable criteria, and analyzing the basis for the appeal
 </li>
 <li>
 Ensures timely review, processing, and response to appeal in accordance with State, Federal and NCQA standards
 </li>
 <li>
 Communicates with members, providers, facilities, and other departments regarding appeals requests
 </li>
 <li>
 Generates appropriate appeals resolution communication and reporting for the member and provider in accordance with company policies, State, Federal and NCQA standards
 </li>
 <li>
 Works with leadership to increase the consistency, efficiency, and appropriateness of responses of all appeals requests
 </li>
 <li>
 Partners with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry best practices
 </li>
 <li>
 Performs other duties as assigned
 </li>
 <li>
 Complies with all policies and standards
 
 
 </li>
 </ul>
 
 Education/Experience
 
 Requires Graduate from an Accredited School of Nursing or Bachelor&rsquo;s degree in Nursing and 2 &ndash; 4 years of related experience.
 
 
 Knowledge of NCQA, Medicare and Medicaid regulations preferred.
 
 
 Knowledge of utilization management processes preferred.
 
 
 
 License/Certification
 
 
 
 <ul>
 <li>
 LPN - Licensed Practical Nurse - State Licensure required or
 </li>
 <li>
 LVN - Licensed Vocational Nurse required or
 </li>
 <li>
 RN - Registered Nurse - State Licensure and/or Compact State Licensure required or
 </li>
 <li>
 LCSW- License Clinical Social Worker required or
 </li>
 <li>
 LMHC-Licensed Mental Health Counselor required or
 </li>
 <li>
 LPC-Licensed Professional Counselor required or
 </li>
 <li>
 Licensed Marital and Family Therapist (LMFT) required or
 </li>
 <li>
 Licensed Psychologist required
 
 
 </li>
 </ul>
 Pay Range $27.02 - $48.55 per hour
 
 
 Centene offers a comprehensive benefits package including competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.
 
 
 Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
 
 
 Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
</div>

Clinical Review Clinician - Appeals

HMSA

<div>
 
 Employment Type
 
 
 
 Full-time
 
 
 
 Exempt or Non-Exempt
 
 
 
 Exempt
 
 
 
 Job Summary
 
 
 
 
 Hybrid Work Environment - Must reside in Hawaii
 
 
 
 
 Pay Range:
 
 $59,000 to $116,000
 
 
 
 Note
 
 : Individuals typically begin between the minimum to middle of the pay range
 
 
 Under minimal supervision, conducts detailed analysis and review of precertification requests, post-service and suspended claims, by applying clinical expertise against HMSA medical and reimbursement policies, plan benefits and nationally accepted clinical guidelines to determine appropriateness of care for all HMSA lines of business.
 
 
 
 Minimum Qualifications
 
 
 
 <ul>
 <li>
 Associates degree in Nursing.
 </li>
 <li>
 Current, unrestricted Nursing License in the state of Hawaii as an RN or LPN.
 </li>
 <li>
 Two years clinical, case management or utilization management related experience.
 </li>
 <li>
 Knowledge of current standards of care to be followed for a given diagnosis and the normative values of medical tests and procedures.
 </li>
 <li>
 Strong organizational skills
 </li>
 <li>
 Good communication skills both verbally and written
 </li>
 <li>
 Analytical skills
 </li>
 <li>
 Basic knowledge of Microsoft Office applications. Including but not limited to Word, Excel, and Outlook.
 </li>
 <li>
 Currently licensed in Hawaii as an RN or LPN
 </li>
 <ul>
 <li>
 (if applicable upon hire, proof of licensure to be provided by employee or confirmed by Human Resources)
 
 </li>
 </ul>
 </ul>
 
 Duties And Responsibilities
 
 
 
 <ul>
 <li>
 Utilize medical necessity criteria from established medical policies and clinical practice guidelines to render precertification determinations as described in the Medical Management UM work plan. This detailed clinical judgment includes evaluating whether the requested service is a covered benefit under the member's health plan, is medically appropriate for the member's clinical condition or whether the request requires referral to a Medical Director for potential denial of the request. The Nurse Reviewer must follow each line of business' requirements and each accrediting body's (CMS, NCQA, HSAG) requirements for each request. Assists on inquiries from external parties such as the State Insurance Commissioner and from the Legal Department. Responsibilities include, but are not limited to:
 </li>
 <ul>
 <li>
 Demonstrate understanding and application of over 250 Guide to Benefits, Evidence of Coverage, Plan Brochure, and Member Handbook. HMSA annually updated medical and drug policies, medical protocols, National Comprehensive Cancer Network, Milliman Care Guidelines, Drugdex, etc. to determine the medical necessity of urgent and non-urgent precertification requests. Urgent requests must be completed within 72 hours and non-urgent requests within 15 calendar days.
 </li>
 <li>
 Use clinical judgment, medical necessity guidelines and plan benefits to determine approval, potential denial or alternative treatment of each urgent or non-urgent precertification request. Settings include inpatient, outpatient, in-state, out-of state and out-of country.
 </li>
 <li>
 Document clinical case summary and review outcome of each review appropriately to meet regulatory and program requirements.
 </li>
 <li>
 Review various types of services, including but not limited to:
 </li>
 <li>
 Transplants
 </li>
 <li>
 Air Ambulance
 </li>
 <li>
 Chemotherapy
 </li>
 <li>
 Clinical trials
 </li>
 <li>
 Genetic testing
 </li>
 <li>
 Cancer treatments/radiation therapy
 </li>
 <li>
 Experimental/Investigational Services/Devices
 </li>
 <li>
 New Technology
 </li>
 </ul>
 <li>
 Utilize medical necessity criteria from established medical policies and clinical practice guidelines to render precertification determinations as described in the Medical Management UM work plan. This detailed clinical judgment includes evaluating whether the requested service is a covered benefit under the member's health plan, is medically appropriate for the member's clinical condition or whether the request requires referral to a Medical Director for potential denial of the request. The Nurse Reviewer must follow each line of business' requirements and each accrediting body's (CMS, NCQA, HSAG) requirements for each request. Assists on inquiries from external parties such as the State Insurance Commissioner and from the Legal Department. Responsibilities include, but are not limited to:
 </li>
 <ul>
 <li>
 Call providers when additional clinical information is required to clarify or complete a complex precertification determination.
 </li>
 <li>
 Approve precertification requests based on clinical judgment using criteria, medical record documentation and other information received from the provider.
 </li>
 <li>
 Consult with Medical Directors on requests which do not meet clinical criteria and offer alternative covered health care options as appropriate.
 </li>
 <li>
 Consult Medical Directors on potential quality issues identified during review of medical records. Refer cases to Integrated Health Management, Pharmacy Department or Benefits Integrity Department depending on the concern.
 </li>
 </ul>
 <li>
 Evaluate suspended claims against medical records to determine the medical necessity and appropriateness of medical services, identify irregularities such as over or under-utilization of services, potential up-coding, over billing, etc.
 </li>
 <li>
 Communicate timely, accurate information either verbally, electronically or in writing using clinical judgment, knowledge of medical/reimbursement policies and plan benefits to providers, members as well as internal MM staff and other internal departments (Claims Administration, Customer Relations, Provider Contracting, etc.). For denied services, ensure the denial, benefit and appeal language are accurate and consistent with department procedures, accreditation and regulatory guidelines.
 </li>
 <li>
 Identify and refer members with specific medical and/or behavioral health needs or complex case management and collaborate with medical and behavioral case management staff. Identify and refer quality of care issues and suspected fraud, waste or abuse to the appropriate departments.
 </li>
 <li>
 Perform pre-screening assessment of incoming pre-certification requests to ensure appropriateness of review. Advises non-clinical staff on clinical and coding questions to ensure correct system processes and entries.
 </li>
 <li>
 Performs all other miscellaneous responsibilities and duties as assigned or directed.
 
 
 </li>
 </ul>
</div>

Nurse Reviewer - Clinical Review Unit

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