Job Summary :
Clinical Care Reviewer II is responsible for processing medical necessity reviews for appropriateness of authorization for health care services, assisting with discharge planning activities (i.e. DME, home health services) and care coordination for members enrolled with a CareSource Management Group line of business, as well as monitoring the delivery of healthcare services in a cost effective manner.
Essential Functions :
Complete prospective, concurrent and retrospective review of acute inpatient admissions, post acute admissions, elective inpatient admissions, outpatient procedures, homecare services and durable medical equipmentCoordinate care and facilitate discharge to an appropriate level of care in a timely and cost-effective mannerRefer cases to CareSource Medical Directors when clinical criterial is not met or case conference is needed / appropriateMaintain knowledge of state and federal regulations governing CareSource, State Contracts and Provider Agreements, benefits, and accreditation standardsIdentify and refer quality issues to Quality ImprovementIdentify and refer appropriate members for Care ManagementDocument, identify and communicate with Health Partners, Care Managers and Discharge Planners to establish safe discharge planning needs and coordination of careProvide guidance to non-clinical medical management staffProvide guidance to and assist with oversight of LPN medical management staffAttend medical advisement and State Hearing meetings, as requestedAssist Team Leader with special projects or research, as requestedPerform any other job-related instructions, as requestedEducation and Experience :
Completion of an accredited registered nursing (RN) degree program is requiredMinimum of three (3) years clinical experience is requiredMed / surgical, emergency acute clinical care or home health experience is preferredUtilization Management / Utilization Review experience is preferredMedicaid / Medicare / Commercial experience is preferredMSL highly preferredIf does not reside in Nevada, must be able to obtain a Nevada licenseCompetencies, Knowledge and Skills :
Basic data entry skills and internet utilization skillsWorking knowledge of Microsoft Outlook, Word, and ExcelEffective oral and written communication skillsAbility to work independently and within a team environmentAttention to detailFamiliarity of the healthcare fieldProper grammar usage and phone etiquetteTime management and prioritization skillsCustomer service orientedDecision making / problem solving skillsStrong organizational skillsChange resiliencyLicensure and Certification :
Current, unrestricted Registered Nurse (RN) Licensure in state(s) of practice is requiredMCG Certification is required or must be obtained within six (6) months of hireWorking Conditions :
General office environment; may be required to sit or stand for extended periods of timeCompensation Range :
$61,500.00 - $98,400.00 CareSource takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package.
Compensation Type : Hourly
Competencies :
Create an Inclusive EnvironmentCultivate PartnershipsDevelop Self and OthersDrive ExecutionInfluence OthersPursue Personal ExcellenceUnderstand the BusinessThis job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an inclusive environment that welcomes and supports individuals of all backgrounds.
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