Want to know what a "day in the life" looks like for an evi
Core Clinical Reviewer? Watch this video to learn more!
THIS POSITION IS LOCATED IN Franklin, TN REMOTE POSSIBILITY AFTER 90 DAYS.
Responsible for all clinical certification activities, which include but are not limited to evaluating telephone, fax or WEB requests for authorization of clinical services from physician offices/and or imaging centers, comparing requests against established clinical protocols and authorizing services or referring requests for expert clinical review as appropriate. Reviews clinical information submitted by providers to appropriate criteria and standards and makes decision to issue a review determination or to refer to physician review if criteria are not met. Maintains current departmental standards related to productivity. Trains in clinical certification, utilization management, URAC and NCQA principles, policies, and procedures. Prepares program correspondence as needed. Serves as a resource for members calling for assistance. Makes outbound calls as required. Refers provider and member complaints, and appeals to appropriate departments. Maintains patient confidentiality in accordance with evi
Core standards established in compliance with HIPAA and State regulations. Provides outstanding customer service ensuring callers receive the highest possible service.
Runs and analyzes reports to ensure all tasks are completed in a timely fashion and meet regulatory requirements. Assists team members in departmental chats, by phone and in person. Acts as training assistant when assigned.
Assist team members with questions, participates in team meetings. Can be assigned to projects to support the department as needed. Performs related duties as required.
First 90 days of employment must be onsite at our Franklin, TN Call Center
Core is committed to hiring and retaining a diverse workforce. We are an Equal Opportunity Employer, making decisions without regard to race, color, religion, sex, national origin, age, veteran status, disability, or any other protected class. Applicants must be able to pass a drug test and background investigation
Minimum Experience RequiredCurrent, unrestricted license as LPN/RN in Tennessee.Must have at least 1 year of acute care, managed care, ER or ICU experience.Required Skills
Minimum Experience: Must have at least 1 year of acute care, managed care, ER or ICU experience.
Our Company and What We Offer
Core healthcare is committed to making a positive impact on healthcare, and also making a positive impact on our employees. evi
Core offers a variety of perks and benefits including, but not limited to:
Flexible scheduling and work/life balance with remote and work from home opportunities
3 weeks of PTO(starting) per year plus paid holidays
Education assistance, tuition reimbursement and professional certifications
Health, dental, vision, and life benefits with employer funded HSA
Comprehensive employee discount program, onsite fitness facilities, and smart casual dress code
Paid Volunteer Community Service Days
Ample opportunities for growth, advancement, and promotion
401k retirement plan with company match of 50% employee contributions up to 6%