Works with Regional Medical Directors to make sound, evidence based clinical decisions regarding the requested cases (treatments and procedures) for IP/OP and performs retrospective clinical reviews utilizing criteria set forth by the client and Medicare (CMS-Centers for Medicare and Medicaid Services) and perform outbound calls to providers.
Performs clinical review of cases received from the specialist team or other departments within CCR, determines if additional clinical information if required, makes a clinical decision to approve or deny a case based on plan coverage, criteria and / or guidelines or pend / refer it to the Regional Medical Directors for further review for medical necessity, and coordinates a peer to peer (doctor to doctor case discussion) review as applicable.
Higher Education Diploma with 1 - 3 years of relevant experience
Choosing a digital partner is about more than capabilities — it’s about collaboration and character.
Unrealistic overhauls and off-the-shelf products ignore what matters most — your unique needs, culture, goals, and your legacy data and technology environments.
At EXL, our collaboration is built on ongoing listening and learning to adapt our methodologies. We’re your business evolution partner—tailoring solutions that make the most of data to make better business decisions and drive more intelligence into your increasingly digital operations.
Whether your goals are scaling the use of AI and digital, redesign operating models, or driving better and faster decisions, we’re here to partner with you to help you gain—and maintain—competitive advantage with efficient, sustainable models at scale.
Our expertise in transformation, data science, and change management helps make your business more efficient and effective, improve customer relationships and enhance revenue growth. Instead of focusing on multi-year, resource- and time-intensive platform designs or migrations, we look deeper at your entire value chain to integrate strategies with impact.
We use our specialization in analytics, digital interventions, and operations management—alongside deep industry expertise — to deliver solutions that help you outperform the competition.
At EXL, it’s all about outcomes—your outcomes—and delivering success on your terms. Share your goals with us and together, we’ll optimize how you leverage data to drive your business forward.
For more information, visit www.exlservice.com.
