Care Review Clinician I

Job Title: Care Review Clinician I

Location: 100% Remote

Duration: 3 Months (High Potential of Extension)

Schedule: 8am – 5pm EST with OT on rotation basis for Saturdays (4hrs) and potential for volunteer OT during the week/Weekend.

Description:

looking for Prior Auth reviews to be performed. ST/OT/PT; HH; DME; Pain; Procedures; Genetics, etc

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) license in good standing.

#IRI-RN

Benefits:
• 401(k)
• Dental insurance
• Health insurance

Work Location: Remote

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