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, 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.
Education and Experience
- Associates of Science (A.S) Completion of an accredited registered nursing (RN) degree program required
- Three (3) years clinical experience required
- Med/surgical, emergency acute clinical care or home health experience preferred
- Utilization Management/Utilization Review experience preferred
- Medicaid/Medicare/Commercial experience preferred
Competencies, Knowledge and Skills
- 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
Licensure and Certification
- 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
Working Conditions
- General office environment; may be required to sit or stand for extended periods of time
- Travel is not typically required
- Fostering a Collaborative Workplace Culture
- Cultivate Partnerships
- Develop Self and Others
- Drive Execution
- Influence Others
- Pursue Personal Excellence
- Understand the Business