Clinical Care Reviewer II - Multi State License - RN - Behavioral Health

CareSource•Dayton, OH

About The Position

Clinical Care Reviewer II – Behavioral Health is responsible for processing medical necessity reviews for appropriateness of authorization for behavioral health care services, assisting with discharge planning activities (i.e. outpatient services, home health services) and care coordination for members. Essential Functions: Complete prospective, concurrent and retrospective review of Behavioral Health services Identify, document, communication and coordinate care engaging collaborative care partners to facilitation transition to an appropriate level of care Engage with medical director when additional clinical expertise if needed Maintain knowledge of state and federal regulations, including 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 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 duties as requested. The CareSource mission is known as our heartbeat. Just as we support our members to be the best version of themselves, our employees are driven by our mission to create a better world for members, stakeholders and providers. We are difference-makers who combine compassionate hearts with our unique business expertise to make every opportunity count. Each claim, each phone call, each consumer-centric decision is a chance to change the world for one member, and our employees look for ways to do that every day. The challenge is, there is no one right way to be the difference and we’re looking for people like you that will rewrite that definition every day. We do what it takes to form creative solutions that make our community and the world just a little better. Discover what it means to be #UniquelyCareSource.

Requirements

Associates of Science (A.S) in Nursing required or Bachelor of Science (B.S) in Social Work required
Three (3) years clinical experience required
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
Current, unrestricted Registered Nurse (RN) Licensure or Licensed Social Worker (LSW) required
MCG Certification is required or must be obtained within six (6) months of hire required
General office environment; may be required to sit or stand for extended periods of time

Nice To Haves

Utilization Management/Utilization Review experience preferred
Medicaid/Medicare/Commercial experience preferred

Responsibilities

Complete prospective, concurrent and retrospective review of Behavioral Health services
Identify, document, communication and coordinate care engaging collaborative care partners to facilitation transition to an appropriate level of care
Engage with medical director when additional clinical expertise if needed
Maintain knowledge of state and federal regulations, including 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 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 duties as requested