Clinical Review Specialist

hace 3 semanas


Guaynabo, Guaynabo, Puerto Rico First Health Care of Puerto Rico A tiempo completo
Job Title: Clinical Review Specialist

The Clinical Review Specialist is a key member of our team at First Health Care of Puerto Rico, responsible for conducting initial clinical reviews to ensure the medical necessity of admissions, procedures, and services.



Responsibilities:


  • Discuss cases with psychiatrists, psychologists, or social workers to determine medical necessity criteria for authorizations
  • Conduct prospective, concurrent, retrospective review and secondary reviews for homebound services
  • Evaluate cases as a secondary reviewer when the initial review was not conducted by the same individual
  • Evaluate the quality, medical necessity, and services provided
  • Provide guidance to non-clinical staff as needed
  • Provide written notice to members and providers via secure email or mail
  • Maintain a registry of all cases by facility/providers and account in the UMP platform
  • Issue services authorizations after the review is completed
  • Maintain up-to-date utilization review documentation in designated platforms


Requirements:


  • Available to travel throughout Puerto Rico
  • Excellent communication and analytical skills
  • Ability to work independently and as part of a team


About First Health Care of Puerto Rico:

We are a leading healthcare organization dedicated to providing high-quality services to our members. Our team is passionate about delivering exceptional care and making a positive impact in our community.



Join our team:

If you are a motivated and detail-oriented individual with a passion for healthcare, we encourage you to apply for this exciting opportunity.



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