Service Determination Specialist II

🕒 il y a 3 jours

🇺🇸 États-Unis – Télétravail

💵 $56 430 - $90 360 / an

⏰ Temps Plein

🟡 Intermédiaire

🟠 Senior

🦅 Parrain de Visa H1B

Cette entreprise a parrainé des visas H1B par le passé.

👻 Score fantôme 0%

Ce que ça veut dire : la probabilité que cette offre reste ouverte sans recrutement actif.Comment le lire : 60 % ou plus, on pense que c'est une offre fantôme. Un score plus bas est moins inquiétant.Comment on la calcule : ancienneté, republications, postes ouverts vs taille de l'équipe, rapidité de clôture, et si le salaire est indiqué.À noter : une estimation à partir de données publiques, pas un jugement sur l'entreprise. De vraies offres peuvent avoir un score élevé, alors prenez-le comme un indice, pas comme un fait.

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CareSource

Site WebLinkedInTous les Emplois

1001 - 5000 employés

Fondée en 30+ years

🏥 Santé

🛡️ Assurance

⚕️ Assurance santé

Healthcare • Insurance • Healthcare Insurance

CareSource est une entreprise de services de santé axée sur la fourniture d'assurances santé abordables et de solutions de soins de santé. Elle propose une large gamme de plans incluant Medicaid, le Marketplace et Medicare Advantage, visant les adultes à faible revenu, les familles, les enfants, les femmes enceintes, les personnes âgées et les personnes handicapées. De plus, CareSource fournit à ses membres des ressources pour le soutien COVID-19, des avantages dentaires, visuels et auditifs, ainsi que des services de pharmacie. L'entreprise met l'accent sur l'accès facile à la gestion des soins de santé via des plateformes en ligne et une application mobile.

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

🎯 Exigences

• 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

🏖️ Avantages

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