About this role
Works with Regional Medical Directors to make sound, evidence based clinical decisions regarding the requested cases (treatments and procedures) for IP/OP and performs retrospective clinical reviews utilizing criteria set forth by the client and Medicare (CMS-Centers for Medicare and Medicaid Services) and perform outbound calls to providers.
Performs clinical review of cases received from the specialist team or other departments within CCR, determines if additional clinical information if required, makes a clinical decision to approve or deny a case based on plan coverage, criteria and / or guidelines or pend / refer it to the Regional Medical Directors for further review for medical necessity, and coordinates a peer to peer (doctor to doctor case discussion) review as applicable.
Bachelor Degree in relevant field with 6- 8 years of relevant experience