Job Details
Job Title: Care Review Clinician I
Location: Remote
Duration: 6 Months
Job Description:
Will the position be 100% remote? Yes
Are there any specific location requirements? No
Are there are time zone requirements? No, EST preferred
What are the must have requirements? UM experience
What are the day to day responsibilities? Review provider requests for Behavior Health services for applicable medical necessity and processing results.
Is there specific licensure is required in order to qualify for the role? LCSW, LPC, or RN
If RN, needs a VA or compact license
What is the desired work hours (i.e
8am 5pm) Tuesday to Saturday, 8am to 5pm EST
Summary:
Works with the Utilization Management team primarily responsible for inpatient medical necessity/utilization review and other utilization management activities aimed at providing *** members with the right care at the right place at the right time
Provides daily review and evaluation of members that require hospitalization and/or procedures providing prior authorizations and/or concurrent review
Assesses services for Client Members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.
Essential Functions:
Provides concurrent review and prior authorizations (as needed) according to Client policy for Client members as part of the Utilization Management team
Identifies appropriate benefits, eligibility, and expected length of stay for members requesting treatments and/or procedures
Participates in interdepartmental integration and collaboration to enhance the continuity of care for Client members including Behavioral Health and Long Term Care
Maintains department productivity and quality measures
Attends regular staff meetings
Assists with mentoring of new team members
Completes assigned work plan objectives and projects on a timely basis
Maintains professional relationships with provider community and internal and external customers
Conducts self in a professional manner at all times
Maintains cooperative and effective workplace relationships and adheres to company Code of Conduct
Consults with and refers cases to Client medical directors regularly, as necessary
Complies with required workplace safety standards.
Knowledge/Skills/Abilities:
Demonstrated ability to communicate, problem solve, and work effectively with people
Excellent organizational skill with the ability to manage multiple priorities
Work independently and handle multiple projects simultaneously
Knowledge of applicable state, and federal regulations
In depth knowledge of Interqual and other references for length of stay and medical necessity determinations
Experience with NCQA
Ability to take initiative and see tasks to completion
Computer Literate (Microsoft Office Products)
Excellent verbal and written communication skills
Ability to abide by Clients policies
Ability to maintain attendance to support required quality and quantity of work
Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA)
Skilled at establishing and maintaining positive and effective work relationships with coworkers, clients, members, providers and customers.
Required Education:
Completion of an accredited Registered Nursing program
(a combination of experience and education will be considered in lieu of Registered Nursing degree).
Required Experience:
Minimum 0-2 years of clinical practice
Preferably hospital nursing, utilization management, and/or case management.
Required Licensure/Certification:
Active, unrestricted State Nursing (RN, LVN, LPN) license in good standing