Service Determination Specialist II

🕒 October 20

🇺🇸 United States – Remote

💵 $56.4k - $90.4k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

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CareSource

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 30+ years

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

CareSource is a health services company focused on providing affordable health insurance and healthcare solutions. It offers a wide range of plans including Medicaid, Marketplace, and Medicare Advantage, targeting low-income adults, families, children, pregnant women, elderly adults, and people with disabilities. Additionally, CareSource provides members with resources for COVID-19 support, dental, vision, and hearing benefits, as well as pharmacy services. The company emphasizes easy access to healthcare management through online platforms and a mobile app.

📋 Description

• Process medical necessity and noncommunity supports and service healthcare reviews for authorization appropriateness, including home and community-based supports • Assist with discharge planning and care coordination for members enrolled with a CareSource Management Group line of business • Monitor delivery of healthcare services in a cost-effective manner • Compare PCSP to provider-submitted service requests to ensure accuracy and need • Conduct front-end and back-end reviews of services approved in Cite Auto Auth or by staff • Work with provider network and Care Coordination to address concerns from clinical quality audits and Cite Auto Auth reviews • Lead collaboration with Care Coordination on transition and discharge plans for members receiving the highest levels of I/DD and BH treatment • Perform prior authorization of BH/SUD/IDD/HCBS/Waiver PASSE services • Process retro-authorization requests and continued stay reviews • Collaborate with Medical Directors and Care Coordinators to ensure the best service is in place • Apply Evidence Based Care systems and applicable guidelines, including MCG, ASAM, and HCBS waiver guidelines • Maintain knowledge of state and federal regulations, state contracts, provider agreements, benefits, and NCQA standards • Apply criteria and processes consistently • Maintain successful inter-rater reliability scores through routine audits • Identify and refer compliance quality issues to Quality Improvement and Network Management • Identify and present clinical cases to appropriate Medical Directors for service determinations • Research to ensure census reports are accurate and up to date • Add services and processes related to new lines of business as requested • Perform other job-related duties as requested

🎯 Requirements

• Nursing degree from an accredited registered nursing (RN) program, Bachelor’s degree in a health care field, or equivalent years of relevant work experience is required • Current unrestricted clinical license in state of practice as a Registered Nurse, Social Worker, Psychologist, or Clinical Counselor is required • Prior experience in utilization review and/or case management working with BH/SUD/IDD/HCBS/Waiver is preferred • Experience with Medicaid, Medicare, Commercial, and Managed Care is preferred • Valid licensure or certification in Substance Use is preferred • Basic data entry skills • Knowledge of Microsoft Word, Excel, and Access • Written and verbal communication skills • Ability to work independently and within a team environment • Familiarity with the healthcare field • Proper usage of grammar • Decision-making and problem-solving skills • Proper phone etiquette • Customer service orientation

🏖️ Benefits

• Bonus tied to company and individual performance may be available • Substantial and comprehensive total rewards package • Equal Opportunity Employer fostering an environment of belonging

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