• Job Description

  Req#: 8792caaa-d8d0-4ee8-a8d8-ec77034a9258
  Clinical Review Specialist Lead
  
  Department: Medical Affairs
  
  Employment Type: Full Time
  
  Location: Remote, U.S.
  
  Description
  
  The Clinical Review Specialist Lead plays a key role in supporting efficient operational workflows through both administrative expertise and clinical knowledge. This team leader is responsible for reviewing patient medical records to assess medical necessity, preparing prior authorization requests, crafting appeal letters, and analyzing insurance policies to ensure compliance and optimal outcomes.
  
  In addition, the Clinical Review Specialist Lead collaborates closely with team members to enhance performance, share best practices, and promote continuous improvement across the department. The ideal candidate displays strong attention to detail, excellent verbal and written communication skills, and exhibits a diligent follow-up practice.
  
  Responsibilities
  
  • Manage and monitor reduced patient caseload, ensuring timely adherence to insurance deadlines.
  • Onboard and train new Clinical Review Specialist hires, serving as the initial point of contact and key team resource. Distribute case assignments strategically to ensure balanced workloads.
  • Conduct bi-weekly caseload reviews with the team, escalating cases and/or questions as needed to the Director.
  • Communicate with physician offices, resolving clinical criteria concerns and ensuring guideline alignment.
  • Review patient medical records, assuring satisfaction of medical necessity criteria for Myomo products.
  • Compose prior authorization requests, ensuring that clinical documentation follows Medicare compliance and guidelines.
  • Craft written appeals in response to insurer-specific denials, completing insurer-specific appeal forms for patient signatures.
  • Analyze and address insurance denials and authorizations, reviewing patient medical records to initiate Administrative Law Judge (ALJ) Hearings when necessary.
  • Audit payer policies, updating internal resources as needed.
  • Facilitate intra/interdepartmental communication to ensure alignment with processes, accurately documenting patient status and updates in the CRM.
  • Ensure strict adherence to HIPAA regulations and organizational compliance standards, meeting with the Director regularly for updates, feedback and performance metrics.
  • Collaborate with the Director to develop and update resources on insurance policies, operational strategies, and authorization/denial trends.
  • Attend departmental and company meetings as scheduled.
  • Meet productivity expectations as outlined in performance goals.
  • Perform any duties assigned by the Director.

• About the company

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