Clinical Care Reviewer II – Behavioral Health, Prefer MA Licensed

🔥 23 hours ago

🇺🇸 United States – Remote

💵 $62.7k - $100.4k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 0%

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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 reviews for authorization appropriateness of behavioral health care services • Assist with discharge planning activities, including outpatient services and home health services • Coordinate care for members • Complete prospective, concurrent, and retrospective reviews of Behavioral Health services • Identify, document, communicate, and coordinate care with collaborative care partners to facilitate transition to an appropriate level of care • Engage with the medical director when additional clinical expertise is needed • Maintain knowledge of state and federal regulations, State Contracts, 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 and support to LPN staff • Attend medical advisement and State Hearing meetings as requested • Assist the Team Leader with special projects or research as requested • Perform other job-related duties as requested

🎯 Requirements

• Associates of Science (A.S) in Nursing required, or Bachelor of Science (B.S) in Social Work required, or Master's degree in a mental health related field required • Three (3) years clinical experience required • Current, unrestricted Registered Nurse (RN) Licensure, Licensed Social Worker (LSW), Licensed Clinical Social Worker (LCSW), Licensed Independent Clinical Social Worker (LICSW), Associate Clinical Social Worker (ACSW), Licensed Mental Health Counselor (LMHC), Licensed Professional Counselor (LPC), Licensed Marriage & Family Therapist (LMFT) or Licensed Mental Health Practitioner (LMHP) required • MCG Certification is required or must be obtained within six (6) months of hire • Utilization Management/Utilization Review experience preferred • Medicaid/Medicare/Commercial experience preferred • 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

🏖️ Benefits

• Bonus tied to company and individual performance • Substantial and comprehensive total rewards package • Employee total well-being support