Clinical Care Reviewer II - MA RN License required - Direct UM experience strongly preferred!

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, as well as monitoring the delivery of healthcare services.

• Essential Functions:
• •Complete prospective, concurrent and retrospective review such as acute inpatient admissions, post-acute admissions, elective inpatient admissions, outpatient procedures, homecare services and durable medical equipment

Identify, document, communicate, and coordinate care, engaging collaborative care partners to facilitate transitions to an appropriate level of care

Engage with medical director when additional clinical expertise if needed

Maintain knowledge of state and federal regulations governing CareSource, State Contracts and Provider Agreements, benefits, and accreditation standards

Identify and refer quality issues to Quality Improvement

Identify and refer appropriate members for Care Management

Provide guidance to non-clinical staff

Provide guidance and support to LPN clinical staff as appropriate

Attend medical advisement and State Hearing meetings, as requested

• •Assist Team Leader with special projects or research, as requested
• •Perform any other job related duties as requested.

• Education and Experience:
• •Associates of Science (A.S) Completion of an accredited registered nursing (RN) degree program required
• •Three (3) years clinical experience required

Med/surgical, emergency acute clinical care or home health experience preferred

Utilization Management/Utilization Review experience preferred

Medicaid/Medicare/Commercial experience preferred

• Competencies, Knowledge and Skills:
• •Proficient data entry skills and ability to navigate clinical platforms successfully

Working knowledge of Microsoft Outlook, Word, and Excel

Effective oral and written communication skills

Ability to work independently and within a team environment

Attention to detail

Proper grammar usage and phone etiquette

Time management and prioritization skills

Customer service oriented

Decision making/problem solving skills

Strong organizational skills

Change resiliency

• Licensure and Certification:
• •Current, unrestricted Registered Nurse (RN) Licensure in state(s) of practice required

MCG Certification or must be obtained within six (6) months of hire required

• Working Conditions:
• •General office environment; may be required to sit or stand for extended periods of time
• •Travel is not typically required

Compensation Range:

$75,200.00 - $120,500.00 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/salary):

Hourly

Organization Level Competencies

Fostering a Collaborative Workplace Culture

Cultivate Partnerships

Develop Self and Others

Drive Execution

Influence Others

Pursue Personal Excellence

Understand the Business

This 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 environment of belonging that welcomes and supports individuals of all backgrounds.

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Brand=Commonwealth Care Alliance