Job Summary
The Clinical Care Reviewer II - Post-Acute is responsible for conducting medical necessity reviews to determine the appropriateness of authorization for post-acute health care services including Skilled Nursing Facilities (SNF), Nursing Facilities (NF), Long Term Acute Care Hospitals (LTACH), and Inpatient Rehabilitation Facilities (IRF). This role assists with discharge planning activities (i.e. DME, home health services) and care coordination for members enrolled with a CareSource Management Group line of business, and monitors the delivery of healthcare services to ensure they are provided in a cost-effective manner.
Essential Functions
- Conduct prospective, concurrent, and retrospective review of post-acute admissions and related services, including outpatient services provided in the post-acute setting according to established processes.
- Complete clinical reviews for new and continued stays in post-acute services; assist in facilitating timely and cost-effective member discharges to the appropriate level of care.
- Refer cases to CareSource Medical Directors when clinical criteria are not met or when a need for a case conference is identified.
- Maintain knowledge of state and federal regulations governing CareSource, including state contracts, provider agreements, CareSource policies and procedures, benefits, and accreditation standards.
- Identify and refer quality issues to the Quality Improvement department.
- Identify and refer members receiving post-acute services to Care Management according to established processes, escalating new or changing member needs as necessary.
- Document member discharge planning needs to support coordinated care and communicate with providers, care managers/care coordinators, discharge planners, CareSource Provider Relations, and other external stakeholders to support discharge planning activities.
- Participate in required inter-rater reliability (IRR) audits to ensure consistency and accuracy in reviews.
- Attend and participate in department huddles, team meetings, and all staff meetings; review meeting minutes and/or other collateral when unable to attend.
- Provide guidance and support to non-clinical utilization management staff as needed.
- Attend medical advisement and State Hearing meetings as requested.
- Assist Team Leader with special projects or research tasks as requested.
- Performs any other job related duties as requested.
Education and Experience
- Completion of an accredited registered nursing (RN) degree program required
- Three (3) years of clinical experience required
- Med/surgical, emergency, acute clinical care or Post Acute Care experience preferred
- Utilization Management/Utilization Review experience preferred
- Medicaid/Medicare/Commercial experience 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 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
- Availability to work scheduled weekend and holiday hours to ensure continuous department coverage and support for reviews throughout the year, including all 365 days
- Travel is not typically required
Compensation Range
$62,700.00 - $100,400.00
Compensation Type (hourly/salary)
Hourly