Look forward to hearing from you. please send resumes to sbenson@nri-staffing.com

Position Type

Full-Time/Regular

Together with our partners, we works to improve health and create a better health care system so that people and communities will flourish.

As a trusted, neutral party, we work with our partners to fix key, intractable health and health care delivery problems. In all our engagements and initiatives, we draw upon our deep expertise in quality improvement, care management, health information technology, analytics, and research and evaluation.

What you’ll be doing:

• Assist providers to submit documentation of requests for case management, utilization review, and other medical management services.
• Enter documentation of requests for case management, utilization review, and other medical management services (collect/enter information into the system that is limited to non-clinical data or is structured clinical data).
• Convey case information and other notifications via inbound and outbound calls.
• Validate the request submitted via the Comagine Health Provider Portal for accuracy and completeness.
• Screen cases for required medical information based on type of request, determining if information is sufficient for clinical review
• Obtain clinical information from the client systems when indicated or contact provider to obtain information required for review.
• Determine based on training when a scripted review is indicated based on contract requirements
• Process requests after physician review, evaluating language and working with physician reviewers, clinical reviewers, or managers to ensure language and determination information is complete before sending letters to providers
• Respond to inbound telephone requests with clear documentation in the care management system of calls.
• Enter case information from original source documentation or validate information entered by providers in the portal
• Make courtesy calls with case reference numbers.
• Provide notification of completed review and additional information needed, when applicable
• Contribute to orientation and training of other non-clinical employees
• As requested, create templates for complex reviews, perform internal quality reviews, and/or participate in provider outreach activities
• May perform scripted clinical reviews and refer reviews requiring further action to clinical review staff
• After physician review, notify providers of decertification or potential denial of services by phone or in writing as required by contract.
• Complete case after physician review, returning to clinician or sending to client based on procedure

Added accountabilities when performing case management support (as appropriate) include but are not limited to:

• Arrange ancillary authorization requests such as transportation, accommodation
• Obtain customer consent for care management services to be performed
• Correspond with facilities, providers, and others
• Coordinate non-clinical functions and intervention, as directed
• Supervised closure of cases upon completion of review by a clinical reviewer, as directed

Required Skills

What would make you a strong fit for our role:

• Intermediate understanding of medical terminology
• Intermediate MS Office Suite proficiency
• Demonstrated proficiency with medical terminology

Required Experience

Required Experience:

• High school diploma (equivalent combination of education and/or work experience in related field may be substituted)
• Post-secondary education or certification in a related field (preferred)
• 2+ years of related work experience or customer service experience
• 2 years of work experience in healthcare; nursing assistant or medical assistant experience (preferred)

if you have the ideal back ground and are interested please send resumes to sbenson@nri-staffing.com