USRN - Clinical Review Specialist II

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Posted 19d ago

What are we looking for?

 

  • Notify members and Providers thru written and phone communications
  • Review plan benefit and clinical information to determine medical necessity of care 
  • Adhere to strict turnaround time to process cases assigned 
  • Recommend appropriate plan of care if criteria of coverage is not met 
  • Review medical records against the standard of care to provide appropriateness of treatment 
  • Communicate to Medical Directors if the request is for possible peer to peer review 
  • Answer internal communications thru email and call about the status of the case 
  • Assist in audit of the previous handling of the case such as the authorization built, appropriate ICD-10 codes, Providers and treatment requests 
  • Refer to Advisor Review if the criteria of coverage is not met 
  • Attend meetings and trainings to stay current with the updates in reviewing of cases

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Company profile

Company Logo for Foundever
Call Centre & Customer Service1,001-5,000 employees

Sitel Group® and SYKES are now Foundever®.

Foundever® is a global leader in the customer experience (CX) industry. With 170,000 associates across the globe, we’re the team behind the best experiences for +750 of the world’s leading and digital-first brands. Our innovative CX solutions, technology and expertise are designed to support operational needs for our clients and deliver a seamless experience to customers in the moments that matter.

Mission: At Foundever®, we make things simple.

Put simply, our mission is to be the solutions and the team behind the best experiences for the world’s leading brands. Wherever and whenever needed.

Perks and benefits
Medical
Miscellaneous allowance
Loans
Dental

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