Nurse Clinical Care ReviewerLocationUS-OH-DaytonJob ID2023-10406OverviewOverviewOn July 1, 2011, Centers for Disease Control and Prevention (CDC), National Institute for Occupational Safety and Health (NIOSH), WTC Health Program was established as a federal health care program to provide medical monitoring and treatment for eligible members in accordance with the James Zadroga 9/11 Health and Compensation Act of 2010. On December 18, 2015, President Obama signed the James Zadroga 9/11 Health and Compensation Reauthorization Act which reauthorized the WTC Health Program for 75 years, ending in 2090.The contractor is to maintain a healthy organizational culture in providing consistent and professional communication and services to WTC Health Program clients including health care beneficiaries and health care providers, the contractor shall participate in the occasionally held lunch/learn and other training sessions regarding WTC Health Program organizational culture.SCOPE OF WORKThe Analyst III (Certification Specialist) position will be filled by a nurse to serve as a Nurse Clinical Care Reviewer for the Medical Benefits and Certifications Unit. The Analyst III position will participate in all aspects of medical benefit decisions for responders and survivors of the 9/11 attacks. These decisions include, but are not limited to, certification decisions for new health conditions and health care benefit prior authorization requests.In addition, the Analyst III may provide recommendations for services that are cost-effective and in compliance with Program regulations and guidelines. The Analyst III will make recommendations based on Program statutes, policy, collaboration with experts, clinical research and their own clinical and professional judgement and analytical skills. Additional duties include managing complex program deliverables, analyzing and manipulating medical claims data and collaborating with occupational health subject matter experts. The Analyst III will interface with clinicians, medical administrators, and a diverse set of federal and contract staff. The work requires excellent organizational, verbal and written communication skills, attention to detail, innovative problem solving, and self-initiation. The WTC Health Program leadership and management team will provide guidance commensurate with the Analyst III's level of duties.Essential Functions and Job ResponsibilitiesReviews and makes recommendations on requests for certification of health conditions, in alignment with Program guidelines and policies, permitting member access to treatment benefits.Analyzes and makes recommendations in writing against Program regulations and guidelines and evidence-based clinical guidelines for clinical service requests from health care providers.Appropriately prioritizes and tracks all certification and prior authorization requests, reviewing them for completeness and alignment with Program policy and requirements; makes recommendations to approve or deny these requests using clinical and professional judgement and analytical skills within required timeframe.Collaborates with subject matter experts when making decisions and recommendations.Requests additional information from providers in a consistent and efficient manner with superior customer service.Liaises with denial and appeal coordinators for denial decisions. Creates denial letters and collaborates with the Office of General Counsel to review.Educates clinical center staff/providers regarding certification requests, authorization requirements, eligibility guidelines, and documentation requirements.Provides analytic support of cost and utilization reporting.Understands complex legislative, regulatory, and/or policy guidance for use in executing daily activities.Monitors, coordi