Clinical Review Specialist
hace 3 semanas
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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