Clinical Care Reviewer II

This is a fully remote position, open to applicants in United States.

📋 Description

• Accountable for evaluating medical necessity reviews to determine the appropriateness of authorization for healthcare services.

• Aiding in discharge planning tasks (e.g., DME, home health services) and coordinating care for members.

• Overseeing the provision of healthcare services.

• Conducting prospective, concurrent, and retrospective reviews including acute inpatient admissions, post-acute admissions, elective inpatient admissions, outpatient procedures, home care services, and durable medical equipment.

• Identifying, documenting, communicating, and coordinating care while engaging collaborative care partners to ensure smooth transitions to the appropriate level of care.

• Collaborating with the medical director when additional clinical expertise is required.

• Keeping abreast of state and federal regulations that impact CareSource, State Contracts, Provider Agreements, benefits, and accreditation standards.

• Identifying and referring quality issues to the Quality Improvement department.

• Recognizing and referring suitable members for Care Management.

• Offering guidance to non-clinical staff.

• Providing support and direction to LPN clinical staff when appropriate.

• Participating in medical advisement and State Hearing meetings as needed.

• Assisting the Team Leader with special projects or research as requested.

• Performing any other job-related duties as assigned.

⛳️ Requirements

• Associate of Science (A.S) degree.

• Successful completion of an accredited registered nursing (RN) degree program is required.

• Minimum of three (3) years of clinical experience is required.

• Preferred experience in med/surgical, emergency acute clinical care, or home health.

• Preferred experience in Utilization Management/Utilization Review.

• Medicaid, Medicare, or Commercial experience is preferred.

• Proficient data entry skills with the ability to effectively navigate clinical platforms.

• Familiarity with Microsoft Outlook, Word, and Excel.

• Strong oral and written communication skills.

• Capability to work autonomously as well as collaboratively within a team environment.

• Keen attention to detail.

• Proper grammar usage and telephone etiquette.

• Effective time management and prioritization skills.

• Customer service-oriented attitude.

• Strong decision-making and problem-solving abilities.

• Excellent organizational skills.

• Current, unrestricted Registered Nurse (RN) Licensure in the state(s) of practice is required.

• MCG Certification must be obtained within six (6) months of hire.

🏝️ Benefits

• In addition to base compensation, you may be eligible for a bonus based on company and individual performance.

• A substantial and comprehensive total rewards package.