Job Title: Care Review Clinician

Location: Remote (USA)

Schedule: Monday - Friday, 8 AM to 5 PM CST

Experience Required: 3+ years of hospital acute care/medical experience, UM experience

Summary:

As a Care Review Clinician, you will be an integral part of the Utilization Management team, focusing primarily on inpatient medical necessity/utilization review and various utilization management activities. Your role is crucial in ensuring that MCO (Managed Care Organization) members receive timely, appropriate, and cost-effective care while adhering to state and federal regulations and guidelines.

Essential Functions:

• Conduct concurrent review and prior authorizations (as needed) according to MCO policy for MCO members as part of the Utilization Management team.
• Identify appropriate benefits, eligibility, and expected length of stay for members seeking treatments and procedures.
• Collaborate with other departments to enhance the continuity of care for MCO members, including Behavioral Health and Long-Term Care.
• Maintain department productivity and quality measures.
• Attend regular staff meetings.
• Assist in mentoring new team members.
• Complete assigned work plan objectives and projects in a timely manner.
• Foster professional relationships with the provider community and internal/external customers.
• Consult regularly with MCO medical directors and refer cases as necessary.
• Comply with required workplace safety standards.

Knowledge/Skills/Abilities:

• Strong communication skills, problem-solving abilities, and effective interpersonal interactions.
• Exceptional organizational skills, with the capacity to manage multiple priorities.
• Ability to work independently and handle multiple projects simultaneously.
• Knowledge of applicable state and federal regulations.
• Proficiency in Interqual and other references for length of stay and medical necessity determinations.
• Experience with NCQA.
• Initiative and commitment to task completion.
• Computer literacy, particularly with Microsoft Office products.
• Excellent verbal and written communication skills.
• Adherence to MCO's policies.
• Punctuality and attendance to support required work quality and quantity.
• Maintenance of confidentiality and compliance with the Health Insurance Portability and Accountability Act (HIPAA).
• Ability to establish and maintain 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 a Registered Nursing degree).

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

Duration: Temp-to-Permanent

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