Clinical Care Reviewer II

Job not on LinkedIn

🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $62.7k - $100.4k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔍🏥 Medical Reviewer

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CareSource

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 30+ years

⚕️ 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

• 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 • Monitoring the delivery of healthcare services • 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 is 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.

🎯 Requirements

• 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 • 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 • 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.

🏖️ Benefits

• In addition to base compensation, you may qualify for a bonus tied to company and individual performance. • Substantial and comprehensive total rewards package.