Clinical Care Reviewer II - RN - MultiState License

CareSource • Dayton, OH

1d

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, as well as monitoring the delivery of healthcare services. Essential Functions: Complete prospective, concurrent and retrospective review such as acute inpatient admissions, post-acute admissions, elective inpatient admissions, outpatient procedures, homecare services and durable medical equipment Identify, document, communicate, and coordinate care, engaging collaborative care partners to facilitate transitions to an appropriate level of care Engage with medical director when additional clinical expertise if needed 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 Provide guidance to non-clinical staff Provide guidance and support to LPN clinical staff as appropriate 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)
• Completion of an accredited registered nursing (RN) degree program 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 in state(s) of practice required
• MCG Certification or must be obtained within six (6) months of hire required

Nice To Haves

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

Responsibilities

• Complete prospective, concurrent and retrospective review such as acute inpatient admissions, post-acute admissions, elective inpatient admissions, outpatient procedures, homecare services and durable medical equipment
• Identify, document, communicate, and coordinate care, engaging collaborative care partners to facilitate transitions to an appropriate level of care
• Engage with medical director when additional clinical expertise if needed
• 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
• Provide guidance to non-clinical staff
• Provide guidance and support to LPN clinical staff as appropriate
• 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

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree
• Number of Employees: 11-50 employees