Care Review Clinician II - RN/LVN/LPN

Location: Long Beach, CA
Date Posted: 07-09-2018
Rapidly growing healthcare services organization is seeking a Care Review Clinician for their Albuquerque, NM location

Job Description:
Seeking a driven and energetic nurse for Prior Authorization that needs to be familiar with prior authorization and what is medically appropriate to request for plan members

-At least 4 years of experience in similar role 
-RN or LPN/LVN only 
-Must be able to type well and comfortable with online applications, everything is online 
-Monday-Friday 8am-5pm 

Summary: Works with the Utilization Management team primarily responsible for inpatient medical necessity/utilization review and other utilization management activities aimed at providing members with the right care at the right place at the right time.  Provides daily review and evaluation of members that require hospitalization and/or procedures providing prior authorizations and/or concurrent review.  Assesses services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines. Essential Functions: � Provides concurrent review and prior authorizations (as needed) according to company policy for members as part of the Utilization Management team. � Identifies appropriate benefits, eligibility, and expected length of stay for members requesting treatments and/or procedures. � Participates in interdepartmental integration and collaboration to enhance the continuity of care for members including Behavioral Health and Long Term Care. � Maintains department productivity and quality measures. � Attends regular staff meetings. � Assists with mentoring of new team members. � Completes assigned work plan objectives and projects on a timely basis. � Maintains professional relationships with provider community and internal and external customers. � Conducts self in a professional manner at all times.  � Maintains cooperative and effective workplace relationships and adheres to company Code of Conduct. � Consults with and refers cases to medical directors regularly, as necessary. � Complies with required workplace safety standards. Knowledge/Skills/Abilities: � Demonstrated ability to communicate, problem solve, and work effectively with people. � Excellent organizational skill with the ability to manage multiple priorities. � Work independently and handle multiple projects simultaneously. � Knowledge of applicable state, and federal regulations. � In depth knowledge of Interqual and other references for length of stay and medical necessity determinations. � Experience with NCQA. � Ability to take initiative and see tasks to completion. � Computer Literate (Microsoft Office Products). � Excellent verbal and written communication skills. � Ability to abide by company policies. � Ability to maintain attendance to support required quality and quantity of work. � Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA). � Skilled at establishing and maintaining positive and effective work relationships with coworkers, clients, members, providers and customers. Required

Education:  Completion of an accredited Registered Nursing program. (a combination of experience and education will be considered in lieu of Registered Nursing degree).                                                                                                            

Required Experience: Minimum 2-4 years of clinical practice. Preferably hospital nursing, utilization management, and/or case management.                                                                                                                  

Required Licensure/Certification: Active, unrestricted State Nursing (RN, LVN, LPN) license in good standing.

Position is contract to perm with a strong chance to go perm as this plan is rapidly growing. Immediate need. Please submit updated resume for consideration
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