Job Summary:
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 and LISW 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
Medical management 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:
$58,000.00 – $92,800.00
Compensation Type (hourly/salary):
Hourly
Organization Level Competencies
Create an Inclusive Environment
Cultivate Partnerships
Develop Self and Others
Drive Execution
Influence Others
Pursue Personal Excellence
Understand the Business