Clinical Reviewer

Company: Centene Corporation
Location: Fairport
Posted on: May 25, 2023

Job Description:

You could be the one who changes everything for our 26 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.
Position Purpose: The Clinical Reviewer performs medical record reviews to determine the quality of care; identifies quality issues and assures compliance with medical record standards and regulatory mandates; works collaboratively with Fidelis Care New York providers and educates them on all aspects of medical record review criteria including QARR/HEDIS; conducts member and/or provider telephonic outreach when needed.
Facilitates healthy relationships between large physician practices, IPAs and Centene. Educates providers on NCQA HEDIS measures and risk adjustment, provides reporting and guidance on standards of care, medical record documentation, and coding. Resolves deficiencies to ensure plan compliance with State and Federal standards. Acts as a resource for health plan peers and supports quality improvement interventions and audits. Involves local travel in the Western NY area (Buffalo or Rochester), dependent on the candidate's geographical location.
Stays abreast to changes in Fidelis' Performance Management measures and systems and changes in clinical guidelines.
Perform reviews of medical records and standards; post completed review reports with the number of records reviewed and quality issues noted.
Collaborate with providers and adhere to clinical standards of care to ensure appropriate outcomes; practice and adhere to departmental, state and national guidelines.
Educate providers on clinical guidelines and QARR/HEDIS measures.
Communicate in an efficient, effective, and friendly manner with providers, internal, and external staff.
Attend educational workshops; review professional publications; establish personal networks; participate in professional societies to maintain professional and technical knowledge.
Travel when required.
Education/Experience: New York State RN or LPN License or FMG required. One year nursing experience, Clinical experience preferred. A minimum of one year HEDIS/QARR Medical record review and audit experience, required. Proficiency in Microsoft Office: Excel, Word,; Internet. Business Analysis Knowledge: Skilled to work in a fast paced environment. Must have strong analytical and problem solving skills. Ability to assess treatment needs and make recommendations that impact desired outcomes and quality of care. Customer Service: Skilled to communicate with all levels of management, internal and external customers. Ability to work well as a member of a team or alone. Effective Business Communication: Skilled in communicating with technical and business constituencies in writing effective business specifications and requirements. Requires proven ability to consistently meet and /or exceed goals. Must be capable of making commitments, setting priorities and delivering results on time.
License/Certification: New York State RN, LPN, LMHC or LCSW license or FMG required.
The salary range for NY is: $25.44 - $45.76 per hour
This information reflects the anticipated base salary range for this position based on current national data. Minimums and maximums may vary based on location. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law.
Our Comprehensive Benefits Package: Flexible work solutions including remote options, hybrid work schedules and dress flexibility, Competitive pay, Paid time off including holidays, Health insurance coverage for you and your dependents, 401(k) and stock purchase plans, Tuition reimbursement and best-in-class training and development.
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law.
Pay Range: $25.44 - $45.76 per hour
TITLE: Clinical Reviewer
LOCATION: Fairport, New York
REQNUMBER: 1415188

Keywords: Centene Corporation, Rochester , Clinical Reviewer, Healthcare , Fairport, New York