Clinical Care Reviewer II - RN - Nevada WFH - Must be Nevada Resident

CareSource

41d•Remote

About The Position

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 Med/surgical, emergency acute clinical care or home health experience is preferred Utilization Management/Utilization Review 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: $61,500.00 - $98,400.00 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. #LI-JM1 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

Completion of an accredited registered nursing (RN) degree program is required
Minimum of three (3) years clinical experience is required
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
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

Nice To Haves

Med/surgical, emergency acute clinical care or home health experience is preferred
Utilization Management/Utilization Review experience is preferred
Medicaid/Medicare/Commercial experience is preferred

Responsibilities

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