Pay: $35.00 - $38.65/hr
Contract: 3 month contract to hire
Location: North Charleston, SC 29405
Hours: Monday-Friday 8:00-5:00
Openings: 5 openings
Under the direction of the Supervisor, the Clinical Care Reviewer (CCR) is responsible for completing medical necessity reviews. Using clinical knowledge and experience, the clinician reviews provider requests for inpatient and outpatient services, working closely with members and providers to collect all information necessary to perform a thorough medical necessity review.
It is within the Clinical Care Reviewers discretion to retain requests for additional information and/or request clarification. The CCR will use his/her professional judgment to evaluate the request to ensure that appropriate services are approved and recognize care coordination opportunities and refer those cases to integrated care management as needed.
- The CCR will apply medical health benefit policy and medical management guidelines to authorize services and appropriately identify and refer requests to the Medical Director when indicated.
- CCRs are responsible to ensure that treatment delivered is appropriately utilized and meets the Members needs in the least restrictive, least intrusive manner possible.
- The CCR will maintain current knowledge and understanding of the laws, regulations, and policies that pertain to the organizational units business and uses clinical judgment in their application.