Clinical Reviewer – Medicare


Be part of something bigger—make an impact in a growing organization! CareCentrix is committed to making the home the center of patient care.

Clinical Reviewers are responsible for the Utilization Management and review of clinical information for service requests received and to render a medical necessity approval or recommended denial to the Medical Director. As part of this process, you will evaluate information concerning patient care and match those needs with available care options, consistent with CareCentrix guidelines and specific plan payer criteria.


In this Job, you will:

  • Perform an initial evaluation of the referral appropriateness for CareCentrix services. Review for information needed to make a medical necessity determination.
  • Request additional clinical information when needed to render a decision and determine next steps.
  • Use clinical expertise, review clinical information and clinical criteria (e.g., CMS, MCGs, Interqual) to determine if the service/device meet medical necessity for the patient.
  • Ensure case review and elevation to complete the determination is rendered within the contractual and regulatory turnaround time standards to meet both contractual and regulatory requirements.
  • Interact with the Medical Director as needed to ensure proper medical necessity decisions are being made in a timely manner.
  • Develops/maintains a working knowledge of all CareCentrix services/guidelines/policies and accesses CareCentrix contract information, including the terms of the contract as appropriate.
  • Peform other duties as assigned by leadership in an effort to support business needs and best serve patients.

This is the job for you if:

  • You can be a clinical resource to department care coordinators, providing expertise and clinical support.
  • You manage multiple tasks, are detail oriented, responsive, and demonstrate independent thought and critical thinking.
  • You possess strong computer skills, including the ability to navigate multiple internal systems, programs and external sites to conduct reviews.
  • You have experience working remotely and are self-motivated.
  • You are willing to work a full time position and can have various work shifts which may be required as needed.


You should get in touch if: (experience & education)

  • You have an Associate’s Degree or Diploma in Nursing/Practical Nursing (required)
  • You are a Registered Nurse/LPN/LVN with Licensure in the state(s) of practice (based on allowable state practice act)
  • You hold an active, current and unrestricted license (required).
  • You have a minimum of 1-2 years prior authorization experience for Medicare or Medicare Advantage Home Health required.
  • You have a minimum of 2 years in a clinical setting (required). 
  • You have 1-2 years’ experience in Interqual (desired).
  • You hold strong knowledge of Medicare PDGM and 1-2 years process experience strongly desired.
  • You hold a broad knowledge of health care delivery/managed care regulations, contract terms/stipulations, prior utilization management/review experience, and governmental home health agency regulations preferred.
  • You possess proficient analytical, negotiation, communication, problem solving and decision making skills (required). 

What we offer:

  • Full range of benefits including Health, Dental and Vision with HSA Employer Contributions and Dependent Care FSA Employer Match.
  • Generous PTO, 401K Savings Plan, Paid Parental Leave, free on-demand Virtual Fitness Training and more.
  • Advancement opportunities, professional skills training, and tuition Reimbursement
  • Great culture with a sense of community.

CareCentrix maintains a drug-free workplace.