Utilization Management Clinical Care Reviewer II - MUST be Multi-State Licensed

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 equipment
• Coordinate care and facilitate discharge to an appropriate level of care in a timely and cost-effective manner
• Refer cases to CareSource Medical Directors when clinical criterial is not met or case conference is needed/appropriate
• 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
• Document, identify and communicate with Health Partners, Care Managers and Discharge Planners to establish safe discharge planning needs and coordination of care
• Provide guidance to non-clinical medical management staff
• Provide guidance to and assist with oversight of LPN medical management staff
• Attend medical advisement and State Hearing meetings, as requested
• Assist Team Leader with special projects or research, as requested
• Perform any other job-related instructions, as requested

Education and Experience:

• Completion of an accredited registered nursing (RN) degree program is required
• Minimum of three (3) years clinical experience is required
• Must be MSL
• Med/surgical, emergency acute clinical care or home health experience is preferred
• Medical management experience is preferred
• Medicaid/Medicare/Commercial experience is preferred

Competencies, Knowledge and Skills:

• Basic data entry skills and internet utilization skills
• 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
• Familiarity of the healthcare field
• 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 is required
• MCG Certification is required or must be obtained within six (6) months of hire

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time

Compensation Range:

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the …